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Burnett County Office of Zoning Administi ator o o <br /> APOLICATION FOR SANITARY — LAND USE — BUILDING PERMIT a 3. <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 Laid Use m i= ce <br /> Ordinance, Sanitation Coded wit all other applicable County Ordinances and the laws and regulations of the State of Wis onsin. 3 n. <br /> OWNE�I M'G ��V�/OG, O <br /> ... . . . ............... . . . <br /> ase pri�1 CONTRACTOR or SURVEYOR or AGENT a C <br /> f.�4. .0.. �..`e ..................................................................... ......... cL <br /> ADDRESS ADDRESS <br /> lS:......�!N!. .:.....s.Stfl. 7................ .................................................................................. ......... 1^, a <br /> ADD SS ADDRESS <br /> Q : <br /> PH... ..... O� Y' PHONE. .................................................................... ......... <br /> ........�r.................................. <br /> PLUMB WELL DRILLER <br /> ...........�.. ..... .`.5............................. .................................................................................. ......... L <br /> ADDRESS ^' ADDRESS m 0, rO <br /> PHONE PHONE w, <br /> Z r <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> 1. Work: 2. New Building Details No. Bathrooms ./y... <br /> New Building A.. Type of Construction: No. Bedrooms <br /> pt Tank GVI <br /> .. ;� <br /> Addition ....... ............................................ Sef�4F .z <br /> Sanitary .L.�..... Size .............. ft. x .............. ft. - .. .. .. SS <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... Soil Type ........ .. ................. .r <br /> Mobile Home Slope .............. <br /> Privy ,,,,,,,,,, 3. escribe exactly, -/ami Pero. Rate ......;,5,-.. ..:... ............ <br /> Well .......... hom ,garage, motel, etc. Dry Well .......... + i <br /> Subdivision ,,,,,,.... Seepage Trench .......... <br /> Camping Unit .......... .................................................... PrivyXlT :(1�ir <br /> -------------------------------------------- Seepage Bed-------- — 1 N i <br /> ('"'... <br /> Location of proposed structures and existing structures,well, sewage systems, roads,etc., should be sketched in Fig. A. Inclu e road <br /> Cr <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highwa inter- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXI TING <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> ---___—_--- ——————— ------------------------ <br /> 5. Lot Size: L'JN Fig. A. 6. Location: W <br /> ft. x .............. ft. . ............................... sq. ft. <br /> 01 <br /> � p <br /> it- <br /> ' 1 <br /> m EAa n� � B' o• f <br /> C C <br /> w m <br /> M <br /> Z 00 D n <br /> O O n ro <br /> 6S <br /> ......................................:....... L/...... ...................................... <br /> Signature off O�wnWr lrr Agent Date <br /> Remarks <br /> : m <br /> . .:.. . ............ .......... ..................................... ....... � p <br /> ........................................................ .............................................. ... ................P44- a <br /> .... <br /> _ 11 ......... ... <br /> Inspection Date / ..................................`-' ...... ..... . .. ...... N u m <br /> ZoningAdmin ator 8: 8 8 8 8 8 n <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures iivolving 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 Adm inistrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />