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BurnettCourity Office of Zoning Administr 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 M <br /> J <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m a <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and <br /> regulations of the State of Wisconsin. d/ - a <br /> 3. E <br /> 1.. .............. ....� Q ............... ...... p <br /> OWNER (Please Print) TRACTOR or$URVEVor AGENT <br /> ls............y 10 <br /> u ........................`.............. .............. .QY........ .......................... ...... <br /> A DRESS A RE % <br /> i <br /> I t................. "............sA-1 �: <br /> oy. ..1ti..... .hn... c�.r..s.... ' 9................. ...! �..... ..z`. ✓ c� <br /> A <br /> RISS ADDRESS <br /> .....y ................... ...� 1. 15. ...-".... .�.:�.e................................. ...... <br /> PHONE PHONE <br /> ...............-.......................................................................... . . . . . . ............................................................... ...... <br /> PLUMBER WELL DRILLER :1 -2 <br /> ........................................................................................... .................................................................................... <br /> . ...... O <br /> ADDRESS ADDRESS n •O <br /> 0 < <br /> ........................................................................................... . ........... ... <br /> ............. ................................................ ...... O .i <br /> PHONE PHONE......... Z „J, r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms ... ...... c i <br /> New Building . . Type of Construction: /.No. Bedrooms ... ...... 6- <br /> Addition /�.�A 4�.p. .........5 C+cc y...j�o✓Y'KSeptic Tank Size Gals. <br /> Sanitary .......... Size .$....,SiSft. x .............. ft. ... ...... <br /> Filling/Grading .......... Height.8.1....... Stories ............... 4a. Absorption Field Site: i <br /> Moving .......... Area ........................................... <br /> Soil Type ............................ ....... r <br /> o <br /> Mobile Home .......... Slope .................................. ....... ^ <br /> Privy .......... 3. Use (describe exactly,'1 -family Perc. Rate ........................... ....... <br /> Well .......... home,garage, motel,etc.) Dry Well .. ....... i <br /> Subdivision � �i Seepage Trench z <br /> __Camping Unit- .......... a L�.�GM.L. Privy .. ....... .� <br /> ---------------------------------------- Seepage Bed--------- <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fi . A. <br /> `f 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 <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersect on. `- <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> ----------------------------------------------------------------------- <br /> 5. Lot Size, �/ ^ Fig. A. 6. Location: <br /> IQQ.. ft. x ..... ....0 fT. - ........ .O11' O.Y...... sq. ft. r.5. ........S�.G..�-....... <br /> i9CYcs A <br /> 1� 0\ � <br /> St <br /> :o 0 <br /> � o <br /> , i <br /> J <br /> m mvmrDmm � <br /> m <br /> M N M - 4 m n n W <br /> 0 � f0 <br /> O yr0 : D <br /> n ; y <br /> o <br /> m � J <br /> C_ <br /> Signa ure of Owner or gen Date c <br /> T: <br /> N <br /> Remarks ............................................................................................................ <br /> o : <br /> ..................................................................................................... .... .................. .... ............................ .... <br /> Inspection Date ....................................... 1.Y.tF 1. CL2C .. .......... v u vOn <br /> m <br /> ........................... <br /> Zoning Admi i trator- 1 S g $ UsNOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary fa ilities before constru <br /> can begin. In the case of sewerage disposal 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 beer 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 AP ROVED. <br />