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e5' 1 C? y <br /> Burnett County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ' <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 °� <br /> retlons of the Slate of Wisconsin i <br /> Al.1.1 r..Tt1... i4)?A1P.....�t�.'.�..5 t?.4r E4•. ::°.!1............................ _ <br /> OWNER (Plew print) SURVEYOR <br /> �+ <br /> (11 I CONTRACTOR or SURVEYOR v AGENT <br /> ....'............................................... .............................................................................. a <br /> ADDRESS ........................................ . <br /> ... .......... <br /> _ ADDRESS <br /> ADDRESS ........................................................ . . . . . ................................................................................. ?N <br /> $(06-')l9p ADDRESS ; <br /> ......... .......... ............................................. <br /> PHONE ......................... ...................................................................... <br /> PHONE .........."""""" <br /> PLUMBER. .. ...................................................................... <br /> . ........... .. . . ....................................................................... <br /> WELL DRILLER <br /> . <br /> . . . ................................................................................ A.... . lSS. .......................................................................... •O <br /> ADDRESS DD..R1.Ell <br /> G <br /> 'N <br /> P............. . . . . .................................................................. _. <br /> HONE . ................................... . < iG <br /> ' . ..................................................... 'Z N N :t <br /> PHONE <br /> DESCRIPTION o - <br /> 1 <br /> 4. Sanitary Facilities: iF <br /> 1. Work. 2. New BuildingDetails No. Bathrooms o <br /> .......... <br /> New BYBdinaType of.Cn <br /> struftc.txi ..: .. No. Bedrooms .......... <br /> ko <br /> ii Ro :ii <br /> W :�Addition k <br /> ... , Se tic Tank Size Gals. ..........Sanitary Size � . ...... . ,,..3 .FlllingfGrading ...... ft. <br /> Height............. �c <br /> � <br /> Stories ....A......... 4a. Absorption Field Site: i <br /> Moving Area Soil Type .................................... <br /> • ........................................... r <br /> Mobile Moms .......... Slope .......................................... <br /> Privy .......... 3. Use (describe exactly,'1 •family Perc. Rate ................................... m ~ <br /> Well <br /> home,garage, motel etc.) Dry Well m <br /> Subdivision 1 — ' <br /> ""••••• Ih.p, y,o�c r n Seepage Trench Z <br /> Camping Unit <br /> '�~ <br /> .................. ....................... Privy .......... <br /> ------------------------------------- .......... Seepage Bed .......... <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc. should be sketched In Fig. A. va <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at ` FL <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. I 1` <br /> ---------------------------------- ————————————— '0 <br /> 5. Lot Size: Fig. A. 6. location: <br /> ft. x .............. ft. — ............................... sq.ft. <br /> .boy:..! u�..3.............................................. '• <br /> N p <br /> j j J, \ <br /> v <br /> 1 <br /> i� <br /> F <br /> I's <br /> T <br /> Z <br /> O <br /> T � <br /> 1 cclrhp roe. <br /> ..c A <br /> N 'l,.�Pe�'L/ _ wwtt� ""^oa'�"Trr� 0 ma ' > > o m <br /> t f�1 M1�rr SMO. am an ; <br /> 8 N G 9 <br /> ........................ .......................... <br /> » ? : m <br /> v <br /> Signature of Owner or Agent ��••"�' �'bg"'"""""" A T C <br /> Date o� • � <br /> Remarks ..... . <br /> ............. ................. ..... <br /> ........................................ <br /> m. <br /> H ' <br /> Q . <br /> ........ .. ................................... N ^ <br /> O : <br /> ........................................................... <br /> ......................................................... p <br /> Inspection Date ....................................... <br /> . .... :.a.............. .�tel' a N a o <br /> Zoning /Administrator 888 g g <br /> NOTE: A preliminary site inspection must made and site approval granted on all structures involving sanitary facilities before construction <br /> can begin. In the case of sewerage disposalal 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 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 specifications 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 />