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Burnett County Office of Zoning Administri for <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT �• 3 ;�,� <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 m <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable Coun y Ordinances and the laws and <br /> PP 3 <br /> regu�ll ns of the State of Wisconsin. 3• a <br /> .6.� �r........l5 !..„. ....................................... . .............. . h. .. .. 5................................. ...... A <br /> OWNER {dleese prin CONTRACTOR or SURV. 6 R or AGENT L <br /> 71 <br /> ADDRESS <br /> . <br /> DRESSA.................... ........5................................... .ADDRESS..................................................................... ...... <br /> W.1. ...�A...... ..n. .:.........4'....�..Sw.'a............. ..................................................................................... ...... <br /> ADDjSS ADDRESS <br /> ........................................................................................... ..................................................................................... ...... <br /> PHO E PHONE <br /> . .. .l: ..................................................... <br /> ;x <br /> PLUMBER WELL DRILLER <br /> ADDRESS ADDRESS <br /> P..H.O...N..E........ .................... _ . .................................... ...... <br /> o............ Zr, <br /> DESCRIPTION 'f'U ' N b y.. r=1{vl ( f.'[! nitary Facilities: g o ° <br /> 1. Work: 2. New Building Detailso. Bathrooms c <br /> Now Building Type of Constru n:, � � No. Bedrooms .. R <br /> .......... <br /> ... <br /> Addition Septic Tank Size Gals. "I .. ZS— » ?.I�' `• <br /> .......... .......... <br /> Sanitary ...�... Site ......... .... ft. x ......./{�.H ft. .. ...... <br /> Fuung/Grading .......... Height..... ..f............ 4a. Absorption Field Site: <br /> g Soil Type ............................ ....... i <br /> Moving .......... Area .......... �Q.� YP o <br /> Mobile Home .......... ... Slope ................... .............. ....... :� » <br /> Privy ,,,.,,,,., 3. Use (describe exact) .1 -famil Parc. Rate ........................... ....... c+ ' <br /> Well .......... home,garage,motel, etc. Dry Well .. ....... a <br /> Subdivision ..�..f�jm.!.�f/... I�``�� ,� Seepage Trench .. ....... o rj p <br /> %. }LrG!ZIC........... <br /> Camping Unit .......... Privy <br /> .................................................... Seepage Bed ... '� � . <br /> ________ _______________________________________________ __ l .n <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Ft(,. A. <br /> :c <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is local d at .�� :C' <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. l `- <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> ___________________________________________________________________ __ Y <br /> 5. Lot Size: Fig. A. 6. Location, <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............. ( r ....Lojtll��................... ....... i.7 i i(77 <br /> Er. <br /> :r <br /> i o <br /> g -1Z <br /> --I <br /> E <br /> a <br /> T <br /> Z <br /> O <br /> m <br /> m <br /> mmrnr ➢ m <br /> m <br /> m Nn�c � nm nn � <br /> 0 0< d C O � 0 3 <br /> O ,n r° <br /> Ofn0 D <br /> Nom . Na ' <br /> O n o 0 <br /> R. m � <br /> 4owner........... ....................... ........ ...................................... x <br /> Signator Agent Date o <br /> o . <br /> T u <br /> v , <br /> N <br /> No : o <br /> o . <br /> .......................................................................................................... . ..................... .....�...p....................... .... <br /> Inspection Date ...................... . 7t�.. ..... M <br /> ................. ... Y.1'.2c2.... ...:. .. .. ... 72L�. . .. ...... v, P v, o in u, m <br /> ........ .... c o <br /> Zoning Admin' rator 8 8 goo g (A <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this appli ation 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 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 APF ROVED. <br />