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(y1 ( rrtf <br /> Burnett County Office of Zoning Administrator �' c <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 o the c o <br /> .� <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 — �. <br /> ...a --may ....... ...s ../... ........................................................ ...... - <br /> OWNER to[,orintl '... �". • .\. •. •••"'. •.'• •••..'• CONTRACTOR or SURVEYOR or AGENT•••••••••-. . -••••'... ....•. <br /> LL w <br /> . !�.4.!1.�!c ......../�N `1.... E c <br /> ADDRESS ADDRESS ;+ <br /> . . .-E'S-S..................................................................... ....... <br /> ADDRESS ADDR.. .. ESi 1 <br /> ........................................... . ............................. ............... .................................................................................... ....... <br /> PHOpPHONE <br /> o .. f h S <br /> PLUMBER WELL DRILLER <br /> v <br /> ADDRESS ADDRESS m 0 <br /> n o <br /> ........................................................................................... . .. ............................................................................. ....... o ,» <br /> PHONE PHON.. .. E Z N r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms .. .a.. O o •...,,,1 <br /> 2/ No. Bedrooms <br /> New Building .......... Type of nstruction: •• ••• ••• g— R <br /> Addition ............. ..h e sur-c Septic Tank Size Gals. .. ....... , <br /> ..... <br /> Se ..........ftSanitary �� Size ...t7..x.... ft. x Cf <br /> Filling/Grading -.,,,,-,.. Height............. Stories ............... 4a. Absorption Field Site: iO <br /> Moving .......... Area ...................... . Soil Type ............................ ....... <br /> . r <br /> o <br /> MoDlls Home Slope .................................. ....... v .. <br /> Privy 3. Use (describe exactl - milt' Perc. Rate ........................... ....... i <br /> Well home,garage, motel,etc.) Dry Well .... 0 <br /> SubdivisionSeepage Trench z ' <br /> .......... ...........................I........................Camping Unit Privy .. .... i i <br /> .......... .................................................... <br /> Seepage Bed X....y <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fill. A. o 'Z;' <br /> FL <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection, < <br /> N <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. p <br /> ------------------------------------------------------------------- --- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq.ft. ...................................................................... ........ <br /> ,van <br /> N O <br /> Sa I O 7 <br /> b <br /> I a <br /> m ;v <br /> Z <br /> O <br /> D <br /> m <br /> e <br /> M <br /> 11�•i co (D -o V) r- D M W <br /> I�j111 m �n� ' am any <br /> 8N •G � O � rp <br /> 0 f D ' <br /> y <br /> N <br /> y <br /> .............................. A . <br /> x m <br /> Signature marks o Owner or Agent Date o : C <br /> ReN <br /> O <br /> 0 O <br /> N D N N m <br /> Inspection Date ....................................... .... .. .... . ..... ... . ................................... . ' ' ut v, p, o O M m <br /> Zonin Administrator 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 fa ilities before construction <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 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 AP ROVED. <br />