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d-n <br /> Burnett County Office of Zoning Administ ator d 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT a' 3 <br /> o IXXJ <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < m -" <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Lad Use c +- <br /> Ordinance, Sanitation Code, and with allotherapplicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 <br /> a — <br /> .......................... ..................... ........................................................ ........ <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT <br /> ...... .................................... .............................................................. ...... — <br /> ADDRESS ADDRESS <br /> ZU. .T.� .. h� 3 ........ <br /> a <br /> d <br /> ADDRESS ADDRESS i 1 <br /> r-'t <br /> ..........lj1f. 4� ....7.1118............................................... .................................................................................. ......... <br /> PHONE PHONE <br /> ........................................................................................... . . . ........................................................................... ......... <br /> PLUMBER WELL DRILLER <br /> O <br /> ADDRESS <br /> . .................................................................................. . . ............................................................................. ......... -. <br /> ADDRESS <br /> o 0 <br /> � o <br /> PHONE PHONE Z ' <br /> DESCRIPTION <br /> 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms <br /> ......... <br /> New Building -....,/ Type of Construction: No. Bedrooms ......... 0 <br /> Addition ,fes , , ... .......... Septic Tank Size Gals. ......... <br /> Sanitary Size ./.�.... <br /> Filling/Grading Height�.1fS3Q.txo.r.l.e..s.....o..J.........f.t.... 4a. Absorption Field Site: <br /> ,,,,,,,,,, Soil Type .......................... ......... <br /> •......•.•.• 'i <br /> 'r.... <br /> Moving .......... Area .......... E <br /> o <br /> Mobile Home Slope ................................ ......... : .. <br /> Privy ....... 3. Use (describe exactly, 1 -family Perc. Rate ......................... ......... <br /> Well .,......,, hom ,garag , motel, et ) Dry Well ......... <br /> Subdivision ........ , Seepage Trench ......... <br /> Camping Unit „ ,,,,,,,, Privy ......... <br /> .................................................... <br /> -------------------------------------------------- Seepage Bed-------- 1 01 <br /> ......... � ! C <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig. A. Includ road I <br /> Q n1 <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property Is located at a highwa inter- a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXK TING f <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. L o' <br /> —---------------------- <br /> 5. Lot Size: <br /> l Fig. A. 6. Location: {),y :R1 <br /> ..�.,�..�... ft. `. ...—�.�...... ft. — .. s. .� .......... sq.ft. '6`- <br /> .................................................................... ......... 1 <br /> 1 ” <br /> N 5 <br /> ° <br /> I <br /> �o D. <br /> 1 <br /> (i Z <br /> 0 <br /> d <br /> V <br /> y S d l c m 0 <br /> -° fNTl � w cm <br /> O N m ro - m <br /> cp ' 0 3 <br /> m <br /> Signature of caner or Agent Date / ) i--�ox 70 <br /> �l <br /> Remarks .............................................................. .. aJ <br /> m <br /> m . <br /> Inspection Date ....................................... .... . . . .VJ.....1.......�"�`:,.kV. <br /> mnm <br /> Zoning Administ4dtor 8 8 S S S (n <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving Sanitary facilltes <br /> before construction can begin. In the case f sewerage disposal systems, a copy of the percolation test must be attached to <br /> this application before a permit will be issu d. Do riot purchase or install a septic tank, do any plu inhinq or Start any build- <br /> ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the inf irritation conveyed here- <br /> with is found to exist. Changes in plans or pecifications shall not lie made without approval oft e Zoning Adm inistrator. <br /> SEWER SYSTEM SHALL NOT BE C VERED UNTIL INSPECTED BY THIS OFFICE SIND APPROVED. <br /> EoJYit-div i- �.D , <br />