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(his d.Rknc <br /> Burnett County Office of Zoning Administrator d 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. y� <br /> o <br /> TO THE ZONING ADMINISTRATOR The undersigned hereby makes application for a Permit for the work described and located as < si + <br /> N <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use <br /> m <br /> Ordinance, Sanitation Cold/e, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin <br /> T1...nr..............lXf.Y.�� ..��. r..�............................. ............................................................................................ V , (� <br /> OWNER Iplea pnn V CONTRACTOR or SURVEYOR or AGENT <br /> V...C.. . .../.Y../'....... .. .................................. . . . . . ................................................................................. aqq 3 <br /> ADDRESS ADDRESS <br /> ........................................................................................... ............................................................................................ <br /> ADDRESS ADDRESS ,� ➢, <br /> PHO .................. 11 <br /> ................ ...................................................... .PHON.E................................................................................ <br /> ............ .........�k+ .......... ................... ... .. ..... ............................................................................................ i V <br /> PLU BER WELL DRILLER :t <br /> ........................................................................................... ............................................................................................ �y � <br /> ADDRESS ADDRESS �.1 <br /> n O <br /> ........................................................................................... ............................................................................................ o ,» <br /> PHONE PHONE Z :�{ <br /> DESCRIPTION 4, Sanitary Facilities: r`.t° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms o <br /> New 8utltltn T No. Bedrooms <br /> 9 .......... ype of Construes+' """ " m <br /> Addition �„}�(, S I h - Septic Tank Size Gals. .......... p <br /> .......... ........... . ................... <br /> 5....... .. .......... 0 i <br /> Sanitary „� $ize .............. ft. X .......�/...., ft. <br /> Filling/Grading ....... Height............. Stories ............... 4a. Absorption Field Site: <br /> Soil Type <br /> Moving ...... Area .................................... o <br /> .... ......................................... <br /> Mobile Home Slope .......................................... .« <br /> .......... <br /> Priv Perc. Rate ................................... <br /> Privy .......... 3. Use (describe exactly, 1 -family <br /> Well .......... home,garage, motel, etc.) Dry Well .......... txQ <br /> Subdivision ,,,,,,,,,, Seepage Trench .......... I <br /> ................................................I... Privy .......... W <br /> CampingUnit .......... .................................................... <br /> Seepage Bed W , <br /> Location of proposed structures and existing structures, well,sewage systems, roads, eta, should be sketched in Fig. A. Incude road W e Ti) <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter ( a <br /> section, show the Intersecting highways and the setbacks required along them and at the Intersection. CLEARLY LABEL EXISTING <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. Q� U <br /> o <br /> ------------------------------------------------------------- ----- <br /> 5. Lot Size: g Fig. A. 6. Location: Q.i Wit, <br /> ................ ft. x .............. ft. — .�?.../'�r�.Y.F...... sq. ft. ............................................................................... <br /> O <br /> m <br /> 0 <br /> 0 o <br /> o � <br /> ° b <br /> 0 <br /> a o o 0 <br /> -o <br /> s 11K-43 Z <br /> o <br /> J] tar v :E Z <br /> 1 n m m <br /> Z Oiam DaT <br /> o n Z7 <br /> c. <br /> W� m <br /> '.... ................. ................................................ ...................................... :moo C <br /> Sig ature of O er or Agent Date X <br /> M <br /> Remarks ....... m <br /> CID <br /> En <br /> ........................................................................................................................................................................................ ,q i <br /> .............................................................................................................. ... ................. .... ........................................... :QJ <br /> 1: . . . . <br /> � d U � o � o � m <br /> Inspection Date ....................................... �: ... ..... . . ...................... <br /> Zoning Administrator 8 0 0 0 0 0 Cm/d <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary tacilltius <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test most be attached to <br /> this application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> with Is found to exist. Changes in plans or specifications shall not be made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />