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Burnett County Office of Zoning Administrator 9 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT m 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described ndp <br /> °, <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of he <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws nd 3 , <br /> regulationsof the State of Wisconsin. / / " . <br /> —S Q 11 h-eve C 6 5r 4 n <br /> YYI a �l eve................................ .... . :..C? �5.................. �.............. ..... X i <br /> OWN (Please print) CO RACTOR or SU RVEVOR or AGENT ; <br /> .(.........13 . .......��...�... ............................ . ... ..t2..................................................................... ...... d <br /> ADDRfissS ADDRESS <br /> ( .... 0 � J53.... ....Cora y��� .... .4 .4 1i ...... .... ............................ <br /> ....... ............... ........ � .. <br /> ADDRESS <br /> m <br /> ADDRESS :^ <br /> ...............7i.�..- ..FC. . . s .3.................. .........3 .i....-..:. . . .................................. ...... J <br /> PHONE PHONE �1 <br /> ........................................................................................... . .............................................................................. ...... <br /> PLUMBER WELL DRILLER <br /> O <br /> A <br /> ADDRESS ADDRESS � C <br /> ........................................................................................... . ................................................................................... ...... O .i <br /> PHONE PHONE P r '� <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> v <br /> i. Work: 2. New Building Details No. Bathrooms R <br /> Nev,Building Type of nstruction: No. Bedrooms .. ....... ; <br /> ::: ,� Septic Tank Size Gals. .. ....... <br /> Addition ry�}- <br /> a. .. ....... <br /> Sanitary .......... Size ....Z .f7.. ft. x ... ... .... ft. i <br /> Fillingfarading •......... Height....LY... .. Stories ....../........ 4a. Absorption Field Site: <br /> �� ��f' Soil Type ............................ ....... r <br /> Moving .......... Area .......... . ... ..N*e . ........ o <br /> MODIIs Home .......... Slope .................................. ....... <br /> . d i <br /> Privy .......... 3. Use (describe exactlyPerc. Rate ..................... ..... ....... <br /> ,�1 -family <br /> Dry Well m <br /> Well .......... home,gars e,motel, etc.) ..... Z <br /> Subdivision .......... ..ki •,Cf�, Seepage Trench .. ....... <br /> .c. .taa. Privy <br /> Camping Unit ,�p� •• <br /> .......... .....�d:V...4.1M11. .... .P...CA'•1......... <br /> Seepage Bed .......... <br /> ----------------- -- I •vi <br /> C <br /> Location of proposed structures and existing structures well sewage systems, roads, etc., should be sketched in Fi . A. <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is Iota 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. : t 0 <br /> ------------------- ---------------- -- i <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq.ft. ...................................................................... ........ 1 <br /> (t`yl <br /> N o <br /> O J <br /> J <br /> O <br /> 0 <br /> Se AAach-ed b1 WSJ 1' r <br /> T <br /> Z <br /> O :� <br /> J <br /> b <br /> R <br /> Dee- Sa,I <br /> � urvmrD m0o � <br /> n wp < > > 0 E E� m <br /> 0 0<_ m C w > > <br /> O N � „ O m m <br /> Z_OD <br /> owJ on : Ml <br /> In <br /> c O O <br /> J . <br /> m C <br /> 04 <br /> 44� 27. x i A : m <br /> Signature of Owner Date g <br /> N <br /> Remarks <br /> v, <br /> ................................................................................................................................................................................ ....... <br /> o . . <br /> o ; <br /> Inspection Date ....................................... . .1..:...... a ..�i .... ....... N N o . m <br /> ..... .. . <br /> ZoningAdministrates g $ g g to <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary acilities before constructio <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this ap Aication 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 c r specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />