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Burnett County Office of Zoning Administre or �' o <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT 6 3. <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described nd <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the T <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws nd <br /> regLAWiOQ§of the State o Wisconsin. A <br /> t. R.... . <br /> e. ..... .............. ..................................................................................... ...... <br /> a c <br /> OWNER (please print) J CONTRACTOR or SURVEYOR or AGENT r <br /> f k /r !Y r�..... � J.............. [L\) <br /> ......... ................ d z <br /> ADDRESS ADDRES /, "' <br /> . . . ................................................................................ ........RE... SS.S-S- ................................. <br /> ADDRESS ADD � "� ' <br /> i Cq <br /> :n <br /> ........................................................................................... ... <br /> PHpNE� E <br /> / <br /> ...I .. :. ..j.......................................... :� <br /> P �.. .. WELL DRILLER �......................*..,..................... ...... <br /> ,... ........... . .,574 ..... ......... ..... <br /> ADDRESS ADDRESS » .off <br /> P..H...O..N..E........... . . ..... ........... ..... . .... ........................................ ....... _ c <br /> O ri <br /> .......... ...... ............ ......... ........... .P.H..O. N. E....... ................ ...... <br /> Vn` <br /> Z v, r <br /> DESCRIPTION 4. Sanitary Facilities: ( o <br /> s th <br /> Baroom ""' <br /> v <br /> i. Work: 2. New Building Details No. �� e'o <br /> g ,,,}(,,,, Type of Construction: <br /> New Building No. Bedrooms ...... <br /> Addition F N' �>, Septic Tank Size Gals. .. ....... � <br /> .......... ... ........... 3 .�, <br /> .. <br /> Sanitary Size ...: .11.... ft. x ....3. ..... ft. O <br /> ''x"""' 4a. Absorption Field Site: •f ri <br /> Filling/Grading .......... Height............. Stories ............... :v sYC <br /> Moving Soil Type ............................ ....... r i <br /> .......... Area ...................................._.`. p o <br /> Mobile Home Slope ............................I..... ....... <br /> .......... <br /> Pert. Rate ........................... ....... ,' <br /> Privy .......... 3. Use (describe exactly '1 -famil m <br /> Well home,garage, motel,etc. Dry Well .. ....... _ ;� '• <br /> .......... Z <br /> Subdivision Seepage Trench .. ....... <br /> Camping UnitPrivy .. .....`. <br /> .......... .................................................... Seepage Bed <br /> Location of proposed structures and existing structures well sewage systems, roads, etc., should be sketched in Fi . A. R Kr <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is Iota ed at {, <br /> a highway intersection, show the intersectio highways and the setbacks required along them and at the intersec ion. W +; `E, <br /> 9 Y 9q 9 :`) , 0. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. __ <br /> --------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ........... sq.ft. ...................................................................... ........ <br /> s <br /> :h o' <br /> � YY <br /> -2b <br /> O <br /> 7 0 <br /> 0 <br /> T <br /> 2 !J <br /> o <br /> d <br /> 31 W 'p rn r' DtD CU -0 <br /> m c 1. m d O C c <br /> O "O' < J J n m <br /> � <br /> O i D <br /> O N J /A O. 9 <br /> n o IDN-� J C <br /> ... . ... .. .. . � '� x o <br /> o <br /> A <br /> Signature o Owner or Agent Date' <br /> ate o <br /> 0 <br /> N . <br /> Remarks m a <br /> v <br /> S : o <br /> ........................................................................................................... .. ....... . . ............................... T <br /> P ��M4 / { [ N N apN <br /> Inspection Date "' "' o o "i m <br /> m <br /> Zonin Administrato - 8 8 8 S o 8 (a <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this ap lication 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 been issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans oi specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE ANDA PROVED. <br />