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Burnett County Office of Zoning Administrator d 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 a <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located 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 <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. c, <br /> 3c, <br /> rl ............................................................................ N <br /> OWNER ( <br /> please print) CONTRACTOR or SURVEYOR or AGENT a V <br /> ....�9 X}y� e ............................................................................ a <br /> ...../.d....Lor- /'?.........(....L...........o......................... ................ ' <br /> ADDRESS 1 p ADDRESS <br /> ... 5. ..'.. �:`.'`�4.... :v.:...... .��..�.L....0................. ................................................................................I........... <br /> ADDRESS ADDRESS <br /> ........................................................................................... aw [ <br /> PHONE PHONE <br /> ........................................................................................... 'W"'E"L........R.ILLE...'L'E'R.................................................................... <br /> PLUMBER WEL D <br /> ADDRESS............................................................................ .ADDRESS.......................................................................,.... 'C <br /> ........................................................................................... ................................................... ....................................... o 0 <br /> PHONE PHONE Z N <br /> DESCRIPTION 4. Sanitary <br /> Facilities: o o ° <br /> 1. Work: No. Bathrooms 4 <br /> 2. New Building Details o <br /> New BuildingT No. Bedrooms ......... o <br /> ype of Construction: ,n <br /> Addition ,,,•, •„•... ..................................... Septic Tank Size Gals. ... � <br /> Sanitary Size ft. x ft. ”"""" <br /> Filling/Grading ,,.,,,,,,. Height............. Stories ............... 4a. Absorption Field Site: i <br /> Moving .................... Area ........................................... Soil Type .................................... <br /> Mobile Home Slope .......................................... .Ci� ro <br /> i <br /> ., <br /> Privy ..,✓ 3. Use (describe exactly, 1 -family <br /> Pere. Rate ................................... <br /> Wel) ..�! home, garage, motel, etc.) Dry Well .......... t <br /> Subdivision .......... Seepage Trench .......... l i <br /> Camping Unit .......... .................................................... Privy .......... <br /> Seepage Bed .......... t <br /> ---------------------------------------------------- -- -^-V <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road \ <br /> setback, side and back yard dimension and location and setback from all bodies of water_ If property Is located at a highway inter- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection_ CLEARLY LABEL EXISTING e <br /> CTBUCTIJRFSAND PROPOSED STRUCTURES AND ADDITIONS. p <br /> ---- ' <br /> 5. LoSI Size: Fig. A. 6. Location: <br /> .... ft. x ft. - ............................... sq.ft. <br /> �J N <br /> n <br /> N <br /> o <br /> O <br /> �`rJy A O <br /> 1� <br /> or <br /> 0 z <br /> 0 <br /> s <br /> tSo: t Q wolL <br /> t <br /> hs' <br /> M arm L N W Z <br /> n C c c m m <br /> 9 Q n l o F <br /> N d o m <br /> a oN. � : mom <br /> z o o' <br /> 1� ° <br /> LraKE F4o.,f o <br /> cn <br /> m <br /> p <br /> Signature of OOJJwner or Agent Date C <br /> Remarks .J7:l:. 7 9 7J 7............................................................................................... T x m <br /> ........................................................................................................................................................................................ -k-4 II <br /> ....................................................................................................................................... <br /> o: <br /> Inspection Date J. m <br /> p <br /> GZm1�../...:.... ............... .... ............................. ' 1 ' N aoO m <br /> U (Nli O 4�i O (li <br /> Zoning Adm nistrator (c $ o o N <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 he attached to <br /> this application before a permit will be issued. Do not purchase or install a septic tank, (Io any plwnhing Or start any build- <br /> ing until a permit has been issued. A permit may be revoker) it 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 />