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Burnett County Office of Zoning Administrator o o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3. o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as �7 :v <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. 3 <br /> t �, rI T• r, a 0 <br /> �� e� S'r . 6�� f <br /> �a.b.................c.C..u.l .r.................................. <br /> OWNER (please print) CONTRACTOR or SURVrYOR or AGENT 0 <br /> .. .. ....�%.h . .........X.F a <br /> ADDRESS ADDRESS c r- <br /> ...�ac•. u.>.... .................W-1.............................. . .......................................................................................... <br /> ADDRESS ADDRESS <br /> ........................................................................................... ............................................................................................ <br /> PHON _ PHONE <br /> � r <br /> PLUMB R J WELL DRILLER <br /> ......."'E'S' .............................................................................. <br /> ........................................................................................... _ <br /> ADDRESS ADDRESS 0 m <br /> j n O —_ <br /> O........................................................................................... ............................................................................................ r <br /> PHONE PHONE <br /> r <br /> DESCRIPTION 4. Sanitary Facilities: ( 0 8 0 <br /> 1. Work: No. Bathrooms I <br /> 2. New Building Details "•' • ••' 0 <br /> New Building ,,.,,,.,., Type of Constcu�tion: No. Bedrooms ...f�. <br /> Addition ,,,,,,,,, x/S I `Ih Septic Tank Size Gals. ,?.�$''0 :C <br /> .......... t.�.................` .. < P <br /> Sanitary �••.••.••..... t. <br /> ..�*.... Size .............. ft. x .............. ft. <br /> Pilling)Grading .......... Height............. Stories ............... 4a. Absorption Field Site: m, <br /> i 1 <br /> Moving .......... Area ........................................... Soil Type .................................... ET <br /> Mobile Home .......... Slope .ate ................................... , \ <br /> Privy ,,,,,,.... 3. Use (describe exactly 1 famil Perc. Rate ............................... ... <br /> Well Dry Well <br /> ,.,,.,..., home,garage, motel, e ) 1 r <br /> SubdivisionSeepage Trench .......... <br /> Camping Unit .......... Privy................ Privy .......... <br /> Seepage Bed <br /> ---------------------------------------------------------------------- <br /> Location of proposed structures and existing structures, well,sewage systems, roads, etc., should be sketched in Fig. A. Include road <br /> or <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- l :T <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING o <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: t <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... <br /> N <br /> s <br /> N o' <br /> o <br /> e well o [� <br /> '� <br /> 01LIG AT <br /> Y 4 Z <br /> Jl <br /> N <br /> �e• J <br /> � A <br /> ;7� Q <br /> D'7 <br /> 3 �*QK yg �d �t.0Z <br /> c <br /> NaC � NIQ OJ <br /> O < C b C m <br /> yam <br /> oZ <br /> 20 na <br /> a m <br /> Signat Owner or Agent Date p <br /> (�� � � �i�.3s�................................................ v <br /> X <br /> Rem s _n <br /> .............._.... ....... ...................................... .... ....... ............ ........... <br /> m <br /> ..............r. ................................................. ..................................................................................................................... 9 t -� <br /> � <br /> .................................................... ............ . . ........................................... <br /> „ <br /> Inspection Date ....................................... ... . . . . ..... . . . . ...................... o o o m <br /> Zoning A ministrator $ $ $ $ $ $ y <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving 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 Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />