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Burnett Counter Office of Zoning Administrator <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ; W <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and '� :0) <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 sem' <br /> regulations of the State of Wisconsin. o• <br /> ��. ...... .`..F�!l�} ...................... .......... Si�7. ..................................................... ...... A <br /> OWNER (pleat print)I CONTRACTOR or SURVEYOR or AGENT :U-)^ $ <br /> .6:x.4....rte% ..... ....sa:........................ . . . . . . . . C 9 <br /> a j <br /> ADDRESS ADDRESS t . <br /> I e4 . ....s-s4.2...3 <br /> ADDRE..S............................ t ....... ............ ADDRESS.......... ..................................................................................... ...... <br /> 9J <br /> � ^ <br /> lam% <br /> PHONE................................................................................ .PHONE...................................................................... .... :GQ <br /> (�P�Et ! t 1 <br /> PLUMBER WELL DRILLER ;( <br /> 1 <br /> .. ......AZT.......�..:........k��..�.?.`...�:.(�..�........................ .................................................................................... ....... o <br /> ADDRESS ADDRESS 0 <br /> �...... . ..1.�3:h ?J...y............................. .................................................................................... ....... Z o � �1 <br /> PHONE / PHONE a <br /> r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms a. <br /> 2. New Building Details •- 'v.-L"" n o E <br /> New Building � Type of Construction: No. Bedrooms .. . — <br /> .......... E <br /> Addition ...........W1(a. �t.3mE Septic Tank Size Gals. .A.... ;� <br /> .......... ... <br /> Sanitary ....A... Size ft. x .. ..... ft. <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area .............. Soil Type ...................... fie-11�. i .o <br /> ........................... . Slope .................��.:... /2 �o <br /> ....... ....... <br /> Mobile Home ,,........ v <br /> Privy .......... 3. Use (describe exactly,) Perc. Rate ........................... ....... d <br /> -family � <br /> Well �e garage, motel,etc.) Dry Well m '• <br /> .......... 1 <br /> Subdivision - Seepage Trench o <br /> .......... .................G:9."F.� ...... /N ...... <br /> CampingUnit .......... .................................................... ��X 3 <br /> Seepage Bed- ------- -- <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. c <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located 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. o <br /> ------------------------------- -- <br /> i <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. - ............................... sq.ft. ...................................................................... .... . <br /> l <br /> o' <br /> o <br /> 0 <br /> O ( ^ <br /> o <br /> f <br /> T� <br /> 0 <br /> d <br /> in � d W 0 C <br /> m <br /> m �n� <br /> co <br /> o, nny <br /> a < > > <br /> oro ,0 3 <br /> Z o D 1 <br /> o N o N n <br /> �� <br /> ..... . ...... ..w.ner. or. .... <br /> A... ................ ....... ... . . ................... <br /> Signatur.... ..e oYOgent.... <br /> �y m <br /> Remark Ev.... <br /> ..................................................................................................................... ..... a ' <br /> .............................I................/••F. 'F.. .l.. ................................................................................................... ..... ti : <br /> o <br /> ......................................ti.............................................................. .... ... <br /> o o . w m <br /> F -7 <br /> Inspection Date . .�. ...... .... .4r1!1�':f11¢�.....:..... .7.1.1. �.......... ..... Off; 9 N o o s m <br /> Zoning Adminis r tor -'�'7"L i�8 $ 8 S $ $ (A <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 app cation 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 or specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE ANDA PROVED. <br />