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,nty Office of Zoning Administrator C Mo <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> N J <br /> 0 <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located a5 '� v, <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. 3 a � G <br /> ............. �. .M..1. .............................................. ......../.�.!. ate.............. .f. a( .m:...................... O <br /> OWNER (please print) CONT ACTOR or SURVEYOR AGENT o. <br /> �G G P /✓ CZ�c ...... s).X............:i2.7.,(n................................................ ; <br /> A,DRESS ADDRESS — <br /> ..... . . <br /> .., ren%..... .s.o...!.G..................... .........5£3..e.h.................� ...................................... <br /> �l <br /> ADDRESS ADDRESS ' <br /> ys.9'.. .�99........ �..x'66- yG 75 <br /> . ............ ...................................4...................... <br /> PHONE PHONE <br /> PLUMBER WELL DRILLER <br /> ........................................................................................... . . ..DR.... . ............................................................................... .O <br /> ADDRESS ADESS I n 0 <br /> < 11�\ <br /> ........................................................................................... ............................................................................................ o O� <br /> PHONE PHONE Z N ' <br /> DESCRIPTION 4. Sanitary Facilities: ° or <br /> ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details o <br /> New Building ,..�(... Type of Construction: No. Bedrooms .......... $ <br /> Addition „•••, ,•, .•........... //Frcaee Septic Tank Size Gals. .......... <br /> Sanitary Size ft. x .....t3: ... ft. .......... <br /> Filling/Grading ,,,,,,,,,, Height.......V. Stories .......�...... 4a. Absorption Field Site: <br /> Soil Type .................... .... ....... .. F i <br /> i <br /> Moving .......... Area .............y�.y....� ... ........ �: o . <br /> Mobile Home .......... Slope .......................................... A » <br /> Priv Perc. Rate ................................... +t <br /> Privy .......... 3. Use describe exactly, 1 �family <br /> Well .......... home,garage, motel, etc.) Dry Well •••• • •• <br /> Subdivision Seepage Trench ' <br /> tx.4.�.G............... ; <br /> Camping Unit ,,,,,,,,,, Privy <br /> .................................................... Seepage Bed W <br /> .......... w <br /> ------------------------------------------------------ N .N <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc., should be sketched in Fig. A. Include road -0 e <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- p a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> 0 <br /> _____________________________ (� 3 <br /> 5. Lot Size: Fig. A. 6. Location: <br /> 0 <br /> ................ ft. x .............. ft. — ............................... s4.ft. <br /> � m <br /> L4o vl ?. <br /> J <br /> J <br /> A.) <br /> O <br /> exsl+• SL lea f <br /> N^° �G W <br /> 1-0 <br /> exl l V �� <br /> v <br /> A <br /> V n < c m <br /> v3 n — E <br /> C d n Ol <br /> Z O o y <br /> O n <br /> fA S <br /> �Co <br /> ....................... p <br /> ..... . �o <br /> Signature of Owner or Ago t Date X <br /> — <br /> Remarks .(-V .. ...... ... ... . ... .6. ................................................................................................................... �' m0 <br /> .....................C✓ S•; ........ ...Y.Q. ................................................................................................ <br /> II <br /> ........................................................................................................ . ....................... ........................... :V . . . . . . <br /> o: w m <br /> 1 N N <br /> InspectionDate ....................................... ..v�/. .xfl ... .... .............. ...... ... . ............ m <br /> Zoning Administ for K 8 88 8 8 8 v� <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 revoker] 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 />