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Burnett County T Office of Zoning Administrator 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 J <br /> o . <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as '� ,� µ Qh� <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. 3171 <br /> F...r..s.�.......s..T..k.r.. .e .a..N................................. A ° <br /> . . ...... . . . . . <br /> r <br /> OWN ER^^(please print) 7;-r— <br /> ........ <br /> T�-_- CONTRACTOR or SURVEYOR or AGENT � °�\?�\ '� <br /> .......R...).......I........s.,. .. ..�.f....T..� . ............................................................................ V <br /> ADDRESSADDRESS <br /> ........................................................................................... ADDRESS Q <br /> ADDRESS <br /> ........................................................................................... ............................................................................................ <br /> PHON .............................................. PHONE V1 i i <br /> ............. .. . ......................................................................... � :� <br /> PLUMBER WELL DRILLER <br /> ADDRESS ADDRESS � n o <br /> ........................................................................................... . ................................................................................... N' <br /> PHONE PHON........E Z <br /> DESCRIPTION 4. Sanitary Facilities: 9 g o i4 <br /> 1. Work: No. Bathrooms <br /> .•.."••.• 2. New Building Details o <br /> New Building Type of Constr cction: No. Bedrooms <br /> Addition Q.,,., /,S./..il+ Septic Tank Size Gals. a � <br /> . .�................... ....... f : < <br /> Sanitary .. ... Size .............. ft. x .............. ft. •.C�J ' ."7 ct-a -I��I i <br /> M. <br /> Filling/Grading ,,,,,,,,,, Height............. Stories ............... 4a. Absorption Field k i <br /> Moving ......... Area ........................................... Soil Type ........................... ............ <br /> Mobile Home Slope ......................... .... .. ...... . <br /> A' o <br /> .......... <br /> Privy .......... 3. Use (describe exact) -fami Perc. Rate ................................. . o <br /> Well Dr Well l ' <br /> home,garage, motel, a y • <br /> t <br /> Subdivision ........., Seepage Trench .......... w <br /> Camping Unit .......... Privy .......... k' ?1C.................................................... <br /> SeepageBed---------------------------------------------------------------------- <br /> Location of proposed structures and existing structures,well,sewage systems, roads etc., should be sketched in Fig A. Include road Z dial <br /> .d ;L' <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- fV a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING G <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. c � o <br /> ---------------------------------------------------------------- <br /> 'h <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... I1� <br /> �• P <br /> N o <br /> O J <br /> o <br /> 0 <br /> O <br /> j <br /> 1 . D <br /> m <br /> Z <br /> XZAO <br /> se <br /> J <br /> N <br /> V\ <br /> N r- T :EW Z <br /> c 2 m c m <br /> N < m m <br /> m <br /> Z o o 0 y n m <br /> O J n <br /> m 3 <br /> m <br /> ...... . .............................. �., p <br /> Signature of ner or Agent atr/ •'�° C <br /> X : 7D <br /> RemarksY,.r.:/.. ..... ....`................................................................................................................. Q <br /> m <br /> s, <br /> ........................................................................................................................................................................................ II <br /> ....................................................................................................... ...... ........ <br /> ��jj GG ..... ... .. ........ ......................................... : .r. . . . . . <br /> Inspection Date ./.:..7....0.. ............... ... . .... ..... ... . .......... ........................................ : 1d: o ER o fn m <br /> Zoning dministrator 8 8 8 8 8 8 tmro <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 conveyer] 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 />