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tiV n <br /> Burnett County. Office of Zoning Administratoror M 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> 0 <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 cep e ' <br /> Ordicance, Sanitation Cade, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> E.x.........Fri% .K. ..y...............I........................ ................................ ........................................................... h <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT m <br /> T...l.......................................................................... .../..l.6... !'... ................................................................ <br /> ADDRESS ADDRESS <br /> . . . 5..... ................ .. ... .. .`.�.9.............. <br /> C U. d <br /> .............. <br /> ADDRESS ADDR <br /> , 3/l0. ......................................... <br /> E <br /> Gi -. .................................................................................. yy { K <br /> PHONE PHON �1+ <br /> 4-: ............,5 � rfr................................ <br /> ............................................................................................ <br /> PLUMBER WELL DRILLER <br /> /�7..J.,......S!(`�4......k!I.h -W4:..4y8 ... ............................................................................................ o` <br /> ADDRESS ADDRESS G) <br /> 11 ` 0 o <br /> ................................................. <br /> PHONE PHONE Z H <br /> r <br /> DESCRIPTION 4. Sanitary Facilities: 0 0 <br /> 1. Work: 2. New Building Details No. Bathrooms o <br /> New Building No. Bedrooms i <br /> Type of Construction: ' <br /> AdditionSeptic Tank Size Gals. .......... <br /> .......... <br /> Addition ............................... .. <br /> .... <br /> Sanitary ....:✓...� Size .............. ft. x .............. ft. .......... <br /> Filling/Grading ,,,,.,,,,, Height............. Stories ............... 4a. Absorption Field Site:/ <br /> Soil Type ., �1 HA....-.doll .(�!r.� <br /> g S.. <br /> Movin .......... Area ........................... ............. 0. <br /> Mobile Home .......... Slope ....... .................. (� <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate .............. .................. i <br /> Well ......... home,ga age, motel, e1;q 1 Dry Well .......... <br /> Subdivision ,,,,,,,,,, / Seepage Trench .......... <br /> ........... ..... .�/f .. . <br /> Camping Unit .......... f/ ...... Privy .......... <br /> .................................................... Seepage Bed <br /> --------------0i <br /> _—_________..fir..-:. -J— i: <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig. A- Include road CQ <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 a <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. N' .� <br /> I o <br /> 5. Lot Size: /0 ACR, Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq. ft. .............................................................................V <br /> C} m <br /> 0 <br /> N o <br /> o <br /> O <br /> s <br /> a <br /> N <br /> a Z <br /> y N <br /> N` <br /> n r d W Z <br /> "O <br /> or n' C N F 0 <br /> Z o m y n m <br /> o ca 5 n <br /> » – 3 <br /> ( pp 0 o <br /> .... r....... .. r. . . .... ............... ..a...-l.�...0__S. ......... (Jul _ <br /> Signature of Owner to Agent Date — <br /> X M <br /> „ <br /> Remarks ......................................................................................................................................................................... � m� <br /> m : <br /> rfl <br /> ........................................................................................................................................................................................ n <br /> ..................................................................................................... . <br /> .... ....................................................I........................ m <br /> Ig. <br /> Inspection Date ....................................... ?- 2.... .. . ...... .............. u o o U <br /> ZoningAdministra or y� S S S S S S 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 be attached to <br /> this application before a permit will lie 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 />