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ryl <br /> Burngtt County Office of Zoning Administrator 3 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 0 a <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the State of Wisconsin. CL <br /> 174 <br /> ...�Qr/.../�..i/.P�fl.4. JS......................................... ....... ............................................................... ...... i <br /> OWNER (pleasdprint CONTRACTOR or SURVEYOR or AGENT <br /> 0933 Clrcf'3f rOi ve .t .................... .ADD...........ES................................................................................ d ,� <br /> ........ ........................... ............. — <br /> ...... . <br /> ADDRESS RS m ' ' <br /> /71a�o Geo ue, rn,c/ <br /> ...................... ....... <br /> ADD ESS ADDRESS <br /> CO/a� 5 - SP Z3....................................... ...... zoo <br /> PHONE PHONE <br /> PLUMBER <br /> ............... ..W..EL.....L...D.RI.. L....LE.. R............................................................... ....... <br /> pQ i <br /> ..&..x...-.�5.....k/e6,31n,...i4lr.15. . 13..... . . . . . . .............. <br /> ADDRESS ADDRESS ......................................................... ....... <br /> », O0 <br /> �1 G-..� Pl,.......................................... ... . . . . o <br /> PHONE PHONE Z r <br /> DESCRIPTION 4. Sanitary Facilities: o o <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details " """' iCJ 00 <br /> New Building ✓ T • •••.... No. Bedrooms .. ....... <br /> .......... Type f nstructyi n: <br /> Addition ....-. Septic Tank Size Gals. .. ....... � z E <br /> Sanitary .......... Size ..... ft. ft. .. ....... . <br /> Flinn (Gradin F . Stories ........... .. 4a. Absorption Field Site: E� <br /> Filling/Grading .......... Heigh .......... . .. i <br /> Moving .......... Area ..../.��.. +�-. Soil TYPe ............................ ....... i a <br /> MobileHome Slope .................................. ....... <br /> .......... .. <br /> Privy .,,,,,,,., 3. Use (describe exactly,'1 -family Perc. Rate ........................... ....... ilv�� <br /> Well home,garage,motel, etc.) Dry Well O <br /> Subdivision .......... ....�. . ].1]sLA/...J j"I.LC......... Seepage Trench .......... o D '/I <br /> Camping Unit / Privy .......... V+ i . <br /> .......... ............................................... .... _ <br /> Seepage Bed ..... -- \ <br /> Location of proposed structures and existing structures well sewage systems, roads, etc. should be sketched in Fi . A. '-�, _ c <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is loca ed at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersec ion. ` <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. __ 0 <br /> ------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: ' <br /> ................ ft. x .............. ft. . ............................... sq.ft. ...................................................................... ........ <br /> iG <br /> N O <br /> O <br /> iV <br /> 0 ice€ f <br /> a mss , <br /> Q) " O <br /> y� <br /> Z <br /> e <br /> iV\ � i O <br /> 1 <br /> R <br /> mc -. 0 m 0 ca c� <br /> o r^o- < o 00 - - m <br /> m Nage - nm nay <br /> 9 < d C N p p <br /> �( O N : `G N 10 m <br /> W 2 O : � � D ' <br /> O d ' <br /> 2 m <br /> / a C) <br /> ( l c C <br /> o N A <br /> A m <br /> . .. ......WIE-, <br /> ........... ........ .. ......... > O <br /> Signa re of Owner or Agent Date oo <br /> T : N <br /> Remarks n <br /> 6) U <br /> ......................................................................................................... ..... .................. .. .. ..... <br /> 9... j N m <br /> Inspection Date ...... .... .... ...... m <br /> Zonin dministrator ' 8 g 8 8 0 o f/1 <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary f cilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this application before a permit will <br /> be issued. Do not purchase or install a septic tank,do any plumbing or start any building until a permit has been issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans orlspecifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND AFPROVED. <br />