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Burnett County Office of Zoning Administrator 01, <br /> --1 <br /> o <br /> APPLICAT40N FOR SANITARY — LAND USE — BUILDING PERMIT ; 3. <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 o- :Q <br /> o <br /> ©..N. ............. ... .................... ~ <br /> a <br /> .. <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT a <br /> �. ... ...... ..... �.�.. .....................................................................I...................... <br /> ADDRE S ADDRESS <br /> ........................................................................................... <br /> ADDRESS 1 ADDRESS [S>J <br /> -s.-.... s ............................ . .................................. ..... ............... ....................... ...... <br /> ........... <br /> PH NEPHONE .......................................................... <br /> ........................................................................................... . . DR. . . . . <br /> PLUMBER WELL ILLER <br /> .......... <br /> ........................................................................................... .AD......D.RES"'E'S".................................................................... —. <br /> ADDRESS S m <br /> 0 0 o <br /> PHONE PHONE Z H <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details •""" " o <br /> New Building Type of struct n: No. Bedrooms .......... J <br /> Addition ,•„•..... ,,,....,. t,Z/4 ,,,,,, Se Ptic Tank Size Gals. .......... ! < <br /> Sanitary .......... size ..2.0...... ft. x ft. '.."'."' i <br /> Fillingt Grading .......... Height............. Stories ............... 4a. Absorption Field Site: i <br /> Moving .......... Area ........................................... Soil Type .................................... i o <br /> Slope �t <br /> Mobile Home O <br /> Privy 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> • <br /> Well •• home,garage, motel, etc.) Dry Well .......... O <br /> Subdivision Seepage Trench "'.'.."' <br /> .......... <br /> ................................... 1 <br /> Camping Unit .......... ... .'..�Kz � Privy .......... \ <br /> Seepage Bed .......... `1 <br /> ------I-- R <br /> Location of proposed structures and existing structures,well, sewage systems, roads, etc., should be sketched in Fig. A. Include road e <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter. l n <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING py a <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: �u <br /> rr��'� u <br /> ...... ft. x.2.S. ft. — ............................... sq. ft. ........................................................................... . .�. i <br /> m <br /> N o <br /> o_ <br /> ,See <br /> N p, <br /> w <br /> ` ``<`' J <br /> 1,v �`' v <br /> 1 " <br /> i© <br /> v\ 7J N r <br /> c <br /> {tn m fAaC . ? F <br /> x F N _. �m m <br /> Y on < m c <br /> O '_^. m ¢ <br /> � Z O O yn � <br /> C or <br /> } L U <br /> m <br /> �- <br /> Signature of Owner or ypeof ate <br /> Remarks. K/S itt4........t.-^4�n!....�.!:� ...lC?.�.. ./5...7.'..................... <br /> ...!b:e:...�: .. .. .:. (........!�°.... u.'.S.... '"n x mp <br /> fe .....° ............. " _ <br /> .. .......... .. .... .. : . .......... .. . ............. ... .. ........................ <br /> ..... . .. <br /> Irl........ � �J O: N T <br /> V i�vvyy D ............. o cNn o uornm <br /> Inspection Date ....................................... . . . . .. .../.....:.... .EQ.{ c ... .......... ° m <br /> ZoningAdmin' trr� ator era 8 8 8 8 8 8 y <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 percolation test must 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 />