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Burnett County Office of Zoning Administrator �' c <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT W 3. <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and p °. <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the 4 <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 h <br /> regulations of the State of Wisconsin. C <br /> F.car...... �.�s ...lea/,4�......................... .... e/ ............................................................... ...... . <br /> OWN" totem print) CONTRACTOR or SURVEYOR or AGENT ; <br /> ....Y�4!rt....../ ........................................................... ........ . .......................................................................... ...... d <br /> ADDRESS ADDRESS <br /> ADD✓LC(G/ /. /................... .ADDRESS..................................................................... ...... <br /> 7. <br /> PHONE ...................................................... .PHONE......................................................................... ...... <br /> PLUMBER WELL DRILLER <br /> :C"Q <br /> X.. -? �—......(��e ?sfe ............. o <br /> ADDRESS ADDRESS n o �l <br /> 7�SJ...� �..:.. . .... ......................................... ... . . . . o <br /> . . ........................................Y....................................... <br /> PHONE PHONE o N r <br /> DESCRIPTION 4. Sanitary Facilities: ° o » <br /> 1. Work: No. Bathrooms 7 <br /> 2. New Building Details ••••• ••• a <br /> New Building .✓.. Type of Construction: No. Bedrooms .......... <br /> Addition Septic Tank Size Gals. . ....0 i <br /> .......... ..............qq../.�................... .....�tlf < <br /> Sanitary ! Size ..G75A1.... ft. x .. .V.. ft. """"•' i00 <br /> Filling/Grading Height............. Stories :.............. 4a. Absorption Field Site: <br /> Moving Area ....... ...... Soil Type .................................... ?� <br /> Mobile Home .......... I</✓ PX a!l CIeC.G�. Slope ...................��yy <br /> Privy .......... 3. Us (describe exactly,'1 -family Perc. Rate .........t7.f............. ....... m i <br /> Well .......... home,garage, m tel, a c.) Dry Well .. ....... m <br /> Subdivision ,.,,,,,,,, ! ./ ,�, Seepage Trench .. ....... o-. <br /> ...... .... 0!T?t .... i � <br /> Camping Unit Unit .......... Privy .. ....... i <br /> .......... .................................. . .... Seepage Bed <br /> -------------------------------------------------------- -- •� <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Ft(. A. \ g <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is local d at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersect on. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. : i p <br /> — ---- — — — <br /> ------ ------------- ----- --- — -- -- - <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq.ft. ....................................................................... .._... <br /> 0 0 <br /> ��A ))) 1. V 1.• 0 <br /> Z <br /> 9 <br /> m <br /> 31 oi -a w r- D W W <br /> � w ca > 0 S`S. E m <br /> �. �a� - amass <br /> 0 4+ O !O m <br /> Z.-•O � D � 1 <br /> 0 <br /> � o 0 <br /> J . <br /> A <br /> x mo <br /> Signature of Owner or Agent Date S <br /> Remarks .�-:.✓"]. ,6' ... ..C..C::.E. ..:::................................................................................................................. <br /> m <br /> u <br /> o : $ <br /> / J......... M <br /> Inspection Date ' jc ..j.:...... / ' L. . . . .. ........ � � � oo nm <br /> Zoning Administrator's 8 8 8 8 8 8 fn <br /> NOTE: A preliminary site inspection must be made and site appr at granted on all structures involving sanitary fa4it'ties before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this application 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 bee issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or pecifications 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 />