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C 1'77C. 4 <br /> Burnett County Office of Zoning Administrator 3 <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 donein cCount awith the ccordance <br /> Ordinances and henlaws and 3 <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable <br /> abley » c <br /> regulations of the State of Wisconsin. o <br /> rff�i .......S 1��• .C1.! _) <br /> ....................... .. ............................................................................................ <br /> "" CONTRACTOR or$URVEVOR or AGENT <br /> OWNER IPleax Print) ^ <br /> RT.... ....cv.�� , .... i..:..sYy3............................................................................................ q <br /> DRESS ADDRESS <br /> AD _ <br /> . .......................................................................................... •, .�� <br /> . . . ................................................................................ ADDRESS <br /> ADDRESS J <br /> ............................................................................................ <br /> ........................................................................................... PHONE <br /> PHONE <br /> pp <br /> .................................................................... J <br /> ................T�lY.. !S. .T..l�:.l...C..................................... WELL DRILLER p <br /> PLUMBER <br /> (2 C 3o f.. . .............................. . .......................................................................................... - <br /> .... ............ ADDRESS o <br /> ADDRESS V. <br /> 1�..�..(.� 1. ' <br /> ». <br /> ............... ...... ..... .... PHONE � <br /> PHONE9 <br /> o U <br /> DESCRIPTION 4. Sanitary Facilities: <br /> No. Bathrooms .•••..•••. :� c <br /> 1. Work: 2. New Building Details No. Bedrooms ..0— <br /> . <br /> New Building .... ... Type of Construction: Oi��OfR Septic Tank Size Gals. 75- <br /> Addition .... <br /> 5-Addition .. . .... ........... . .V' <br /> Sanitary ...x... Size .............. ft. x .............. ft. 4a. Absorption Field Site: <br /> FiilingfGrading Height........... Stories .....�......... Soil Type ................. :t�..... ` .» <br /> Moving .......... Area .............]...4"�F................... Slope .%P.. .C?.�.�/ <br /> 71 <br /> Mobile Home m ' <br /> .......... Perc. Rate ................................... <br /> Privy 3. Use (describe exactly,F.family Dry Well fD .u1 <br /> ome garage, motel,etc.) z . <br /> Well — Seepage Trench •• •• o <br /> I?I Z <br /> subdivision UC7 "•••'A�(�. Privy ..... .... �� <br /> Camping Unit . ................ Seepage Bed..................... `c <br /> shoul <br /> dE, <br /> Location of proposed structures and existing structures, well, <br /> and location and setback from ale systems, abod bodies of water. If besketched <br /> s Ito al ed at •� •'� <br /> Include road setback,side and back yard <— <br /> ahighway intersection, show the intersecting highways and the setbacks required along them and at the intersection. .� ? ,4 <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. __—_—_ _— <br /> t , <br /> _____________________________________________________ __ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ............... :...Ai�zlq.....:........................ <br /> �C7 C ft. — ............................... sq.ft. <br /> ... ft. x . ......... <br /> o � <br /> 0 <br /> s i1 <br /> 0 <br /> ' i Z <br /> "QLD <br /> nod r- > 000' rt <br /> Np <br /> ms d a m n a 3 <br /> 9mcy = =' 3 <br /> y C N p p b <br /> Z g o D . <br /> c R <br /> Q6 a � 0 : L <br /> C <br /> 4'�. ...............Date n% <br /> Signature o Owner or Ayge gym <br /> �p ............................................................. .... <br /> .................. ...... _. : a . <br /> Remarks ...1./� 2 C��dZllyl m <br /> c <br /> .......................................................................................................................................................................... ........ <br /> .... .. $ , 8 <br /> .................... . ......... ..................... . .. ..... <br /> ... ........................................................................................ .. .. , <br /> N <br /> Inspection Date ................... ................... Zoning Adminlstr r <br /> efore <br /> ion <br /> NOTE: A preliminary site inspection must be made and site apopro„aalpgranted <br /> on all <br /> structures <br /> e attached involving <br /> isanitary <br /> this apfplioatlion before a permitwill <br /> can begin. D the case of sewerage disposal systems,a Copy <br /> be issued. Do not purchase or install a septic tank, do any plumbing or start any building until a permit has been issued. io permit may be <br /> onveyed herewith is found to exist. Changes in plans or specifications shall not be <br /> revoked if misrepresentation of any of the information c <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />