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Surrnett County Office of Zoning Administrator Us Too o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 0 <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 <br /> Ordinance, Sanitation Code. and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin_ <br /> O <br /> ......L.1j.Irr............................................. ............................................................................................ m N <br /> OWNER ((ppleas /print) �{/p CONTRACTOR or SU RVEV OR or AGENT <br /> �....�`-'.fV LJ... /.! 1.}./v *J..%/.f.l....��...... Ce- <br /> ADDRESS ADDRESS ;r <br /> ADDRER..y.. <br /> ..Da...�. ..J........../../../. � .P.a�.f�..1.�.1......... ............................................................................................ \ ^� <br /> ADDRESS �� IY1 <br /> _ / •^ -7 <br /> .CGF . .. ...'S.. <br /> PHONE G..... ..3............................ .PHON.E........................................................................... <br /> ..... <br /> .......................................................................................... ............................................................................................ <br /> T <br /> t .: <br /> PLUMBER WELL DRILLER \\ <br /> ADDRESS ADDRESS <br /> < I <br /> ........................................................................................... ............................................................................................ o' <br /> PHONE PHONE Z J r. i' <br /> DESCRIPTION 4. Sanitary Facilities: ° 0 ° <br /> 1. Work: 2. New Building Details No. Bathrooms .......... o ' <br /> New Building .,,.,,..., Type of Construction: No. Bedrooms .......... > ' ) <br /> Addition .................................................... Septic Tank Size Gals. .......... <br /> Sanitary ...I...... Size .............. ft. x .............. ft. .......... ^� i <br /> FillingtGrading .......... Height............. Stories .............., 4a. Absorption Field Site: <br /> .......... ....... ....... q� aMoving Area ...................... Soil Type .................................... �i <br /> o <br /> Mobile Home Slope .......................................... <br /> » <br /> .......... U 1 <br /> Privy ,,..,,.... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Well .X.... home,garage, motel, etc.) Dry Well .......... <br /> subdivisionSeepage Trench .� <br /> Camping Unit ........ . <br /> .. ............................................... .... Privy .......... (1 <br /> Seepage Bed .......... <br /> _.--------- ----_.--------------------------- ------------------ N <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include •oad t <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 /> _Q <br /> section, show the intersectinq highways and the setbacks required along them and at the Intersection. CLEARLY LABEL EXISTING vl vl <br /> 0 <br /> STHUCTU RES AND PROPOSED STRUCTURES AND ADDITIONS Q o <br /> 5. Lot Size: Fig. A. 6. Location: i <br /> ................ ft. x ............ . ft. — ............................... sq. ft. ............................................................................... <br /> 0 <br /> o <br /> 0 <br /> Jt� T M <br /> Y O <br /> 7J <br /> Y, d <br /> J <br /> M rVA/ V <br /> M � <br /> 0 MUs n <br /> C _ <br /> m 9 <br /> ixe 1 a £ <br /> N C d W <br /> o � 0 am <br /> 2 Z oo' a 70 <br /> no or 1 <br /> _ w� <br /> .. . . . . ................... .....7.-.L..7..-... o c <br /> z <br /> m <br /> Signature o w er or Agent Date <br /> Remarks ............ . ...,.,GSA....... .............. ..... .......... .. X <br /> .......... ...... <br /> .................................................................................................................................. ....................... ' <br /> ;� II <br /> .......................................................................................... .... .......... ...........�Admi <br /> .... / ✓ 1, <br /> En <br /> Inspection Date ....................................... .. ... .. ... ... N ca o T <br /> U !NT O <br /> Zr C 0 0 0 0 0 0 cn <br /> NOTE: A preliminary site inspection must be made and site approval granted On all structures involving sanitily facilitics <br /> before construction can begin. In the case of sewerage disposal systems, if copy of the percolation test must he 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 heart issued. A penult may be revoked if misrepresentation of any of the information conveyed here- <br /> with Is found to exist. Changes in plans of specifications shall not me made without approval of the Zoning Administrator . <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECFED BY THIS OFFICE AND APPROVED. <br />