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(•. /fC c-- I)Ij—, <br /> Burnett County Office of Zoning Administrator 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> 0 <br /> TO THE ZONING ADMINISTRATOR The undersigned hereby makes application for a Permit for the work described and lac ted as < N <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m C <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wls onsln. a <br /> L� ....Jr9� .....L�..r�1LCr-................... ...jr .n........�..�.M.. R` <br /> OWNER (please print) CONTRACTOR or SURVEY_Q or AGENT <br /> o / 3 Trr-gc <br /> /!,. ... ...... �'X....v�. .� ..G............................ ...........3.......7..`.................................................... .......... v <br /> ADDRESS ADDRESS <br /> �J! <br /> .....�.Yrfp. ..................s..... ...... .... ............ .."..... L3. Q <br /> Ir rte• a <br /> ADDRESS / ADDRESS <br /> RHO.I.l..E....P...1?..(?.. v..+S.................................................... PHONE <br /> ... .... .Q ...................................... ..... <br /> .. <br /> . ......... ................................................................................. ..........U' <br /> PLUMBER P WELL DRILLER <br /> ESS <br /> - p <br /> ........................................................................................... ...... -................................................................... ..........-1- <br /> ADDRESS ADD..iESS o _ <br /> ........................................................................................... ................................................................................. .......... 5 .; <br /> PHONE PHONE Z r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details <br /> New Building y No. Bedrooms .. z <br /> ...11. Type o Construction: " .Z n; <br /> Addition LO Septic Tank Size Gals. .......... <br /> .......... ....... .... ....................... ............... < <br /> Sanitary ...X..... Size ft, x ft. <br /> Filling/Grading .......... Height............. Stories ..... ........ 4a. Absorption Field Site: <br /> Moving .......... AreaSoil Type ............................ <br /> Mobile Home ..... .............................. <br /> ........ o <br /> ........................................... Slope .......................................... <br /> ..... <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ....................... ........... <br /> Well .X.... home garage, motel, etc.) Dry Well .......... <br /> Subdivision l f{7V1 / _V e*. Af. Seepage Trench ......... i <br /> ..... .... ... ....... . ............. .... ... .... <br /> Camping Unit Privy .......... <br /> .......... .................................................... <br /> Seepage Bed .� <br /> ------------------------------------------------------------ <br /> Location of proposed structures and existing structures, well, sewage systems, roads etc_, sho..ld he sketched in Fig A. InCI de road 7J � <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a hichw y inter- © o- <br /> section, show the Intersectir,q highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING o <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. 5 <br /> ---------------------- ------------------------------- <br /> 5. Lot Size: -3.0.c) LL................. Fig. A. 6. Locatjo6 G. /���� / _ <br /> ................ ft. x ... ft. - .... Y sq.ft. LL 3 Lz....... <br /> . 1 <br /> T m <br /> MN o <br /> O <br /> !- ° <br /> I add s <br /> _ a <br /> v z a <br /> o <br /> I \ <br /> ;A <br /> c d m <br /> m `J a n m E <br /> < <br /> 3 a -o' chit <. w q m <br /> Z 05 a n <br /> ....... .. .... .. <br /> �� If <br /> If <br /> Signature of Owner or Agent -._._..._ - ate 411 6'✓ S' -�) o C <br /> Remarks .......... F ... + /7 � ..... r <br /> X <br /> .... .... .... . ...�� 1 . �... ..r.�.� r rr�� T. <br /> ---�....... <br /> ................................... ........... ...... . ................................. .. ... <br /> Inspection Date � 1r(.G ro N <br /> ....................................... ... ....ning. . . .. . .......... .... S u, cn o <br /> Zonin Admmi ator <br /> 88 <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolitic in test must be attached to <br /> this application before a permit will be Issued. Do not purchase or install a septic tank, do any p umbing or start illy build- <br /> ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the i iformation conveyed here- <br /> with Is found to exist. Changes In flans or specifications shall not be made without approval of the Zoning Administratol . <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />