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c9? 'G2 <br /> Burnett County Office of Zoning Administrator o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT . <br /> M s <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described nd t <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the o t <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws nd 3 <br /> regulations of the State of Wisconsin. a <br /> M. '..f...✓% . :..... ! .�.�...M.yewzA.Y......... ..................................................................................... ...... , <br /> OWNER fplease print) CONTRACTOR or SURVEYOR or AGENT <br /> �'F.l.....n�. 3.`. ............................................................................ ...... c <br /> ADDRESS ADDRESS <br /> �SlL'. ? �f..N�'........w .....`........`....:3.................. ..................................................................................... . :Q1 <br /> ADDRESS ADDRESS ' <br /> ........................................................................................... . . ........................................................................... ...... <br /> PHONE PHON...... ..E <br /> S !.3�°.7 . �:...- . . . ................................. . . ......... . .. .................................................................. ...... <br /> PLUMBER WELL DRILLER <br /> T........................................................................................... .A..........ES..S... ..................................................................... ...... <br /> ADDRESS DDRm 0 i� <br /> e o <br /> ct c <br /> ........................................................................................... ..................................................................................... ...... O » <br /> PHONE PHONE Z �]„ r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° �--i-a <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details •••• c <br /> New Building ..x... Type of Costruction: No. Bedrooms ... ...... <br /> ......... <br /> Addition ......N,��,.(?.fnt••¢ .,.....r.. ........... .. Septic Tank Size Gals. ... ...... <br /> Sanitary .......... Size ... 2 ft. x .. 32'.. ft. .......... <br /> Filling/Grading Height.../O...... Stories ....l......... 4a. Absorption Field Site: <br /> Moving .......... Area ................................ .......... Soil Type ............................. ......'I: <br /> Slope .................................. - o <br /> MODIIe Home .......... l�� r <br /> i <br /> i <br /> Privy 3. Use (describe exactly, 1 -family Perc. Rate ........................... .....' l <br /> Dry Well <br /> wsu .......... home,garage,m tel, etc.) im <br /> p `5�� z _ <br /> Subdivision .......... ...l...a�t.......!.1.4/..�.d/..l`J. ... Seepage Bed ...... o i <br /> Seepage Trench .. . <br /> Priv <br /> Camping Unit ,,........ � : r <br /> ............................................. ...... ,, CCll <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fi . A. (� g <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is local d at r <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 /> ------------------- ---------------------------------- —r\ (_ <br /> 5. e: �) <br /> a�G )J Fi A. 6. Location: <br /> T.l ..... ft. x 3 �. . . ............................... sq.ft. ................t_J��V I I ...�: ....................... ....... <br /> N 00 <br /> I ] <br /> See <br /> DI ] <br /> . s <br /> v <br /> T <br /> I T <br /> O <br /> :0 <br /> d <br /> M <br /> M <br /> (✓ <br /> SDamsa �o <br /> a c< d <br /> co <br /> om < 0oom <br /> o w0 D <br /> u ] yn S <br /> n <br /> 20 m <br /> �v � ] . O <br /> A <br /> m <br /> ... ... ...... a O <br /> Signature of_4wner or Agent Date c <br /> m <br /> m •� <br /> N <br /> g <br /> ..... .... <br /> Inspection Date ....................................... ..�.... .. ..... . . <br /> . .... <br /> Zoning Adminrator <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 appl cation 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 bee 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 APPROVED. <br />