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i''/i L?,:y? <br /> Burnett County Office of Zoning Administrator W - 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d' 3 <br /> < 0 4 <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m C <br /> Ordinance, Sanitation Code' d with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. o- <br /> �� \ <br /> `vtld..P..r..........a..dP�..9.y... oG! ./a.. 3 n <br /> ........................................ <br /> .......... . ..................... ............. . . _ <br /> OW R (please inti CONTRACTOR or SURVEYOR or AGENT o. <br /> .... 0N.Z........��...... . �3 d a . <br /> AD ADDRESS <br /> ............................................................................................ <br /> �Ue�Z�a-o-d7-i-1�2/Z .e.9--eJ ADDRESS <br /> v�Cl <br /> . .....�........ f ...... ... .......................... ............... . ...... . . ............................................................................... \ <br /> ADDR SS �oX'/19C ADDRESS \ '� <br /> .........................................., /6 <br /> ....�A:,t+,.. . ..,... ........... ............................................................................................ <br /> HON'%i / PHONE tom' U, <br /> . � Y �..•........ . ...... .. . . ....................................................................... <br /> PI-al �1���' I/ WELL DRILLER <br /> P174- <br /> .. . .t ... - J ......... .DRESS ADDRESS............................................................................ �\ <br /> ...../..... .. .. ..d................. .o <br /> m M....... n 0 <br /> ....................... ............................................. <br /> y.................a o`3 <br /> N <br /> PHONE Z � <br /> DESCRIPTION <br /> 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms ....�... <br /> 2. New Building Details <br /> No. Bedrooms rZ. a <br /> New Building ,,. Type of Construction: N <br /> Addition ...X... „`j,(J Septic Tank Size Gals, 7,SOU) <br /> Sanitary .... <br /> ...?5.... Size ......... ... ft. x ....�.p.... ft. ...... <br /> Filling/Grading g 4a. Absorption Field Site: <br /> ... ...... Hei ht... ...... Stories ............. . <br /> Moving ... ...... Area ........................................... Soil Type .................................... <br /> r <br /> Mobile Home .......... Slope .................................... ..... c <br /> •+ <br /> Privy ,..,,,,... 3. Use (describe exactly, 1 -family <br /> Pere. Rate ................................... o i <br /> Wen ,,,,.,,,,, home arae otel, etc.) Dry Well .......... �s f <br /> Subdivision Seepage Trench .......... np <br /> Camping Unit .......... Privy .......... i <br /> .................................................... Seepage Bed <br /> Location of proposed structures and existing structures well, sewage systems, roads, eta, should be sketched in Fig. A. Include road kN <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- °- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING rr <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONSa,, <br /> o' <br /> -- ------------------- ----- ---------------------------- <br /> 5. LSize: Fig. A. 6. Locatio <br /> .d- .�.. ft. x .... S0 ft. . ............................... sq. ft. c..%. ..... <br /> a <br /> N <br /> m <br /> n <br /> N O <br /> . ago o <br /> w <br /> tK o <br /> .�L o <br /> N�Cf[I/Cin. <br /> 013 o <br /> v o z <br /> u w � <br /> 0 <br /> 77 (n r v � 2 <br /> o <br /> �c = <br /> -a <br /> on <' <br /> „ m `— m <br /> z o o ]0 <br /> Ego <br /> m <br /> ..... ✓� .......e.....t . ..... ........... ..... ....5.......�.'... .�..5�... °1 c <br /> Signat( ure of Owner or Agent Date i'C� <br /> Remarks X <br /> U.� ..��.c ? ............................................................................................................................ r pm <br /> v <br /> laa ' <br /> *O II <br /> cr.................................. .. ............. /....................... to <br /> Inspection Date ^ rl....... . ....... .. ............................. m <br /> M <br /> Zoning AdV111strator 8 8 8 8 8 8 rn <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 revoked 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 />