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i r i. (J, ,,A/, <br /> Burnett-County. Office of Zoning Administratord o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as <br />.hown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use <br /> Jrdinance, Sanitation Code and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin 3 <br /> • J t � <br /> .�� :!1rkJ.. - l cr.✓ipyJ �Y,, �!U ./..O e�,'`/�Ct./1..: .... .� -:i_.................................................................. <br /> NER (please pay <br /> print) r ~ ' CO TRAC`FDR or SURVEYOR or AGENT a <br /> ................................ ........................... <br /> ............................................................................ .ADDRESS.. .. ... .. ............. . ......... a i\ <br /> 4DDRESS <br />............... .............r.............................................................................. \ :' <br /> ADDRESS ADDRESS <br />.. ........................................................................................ ............................................................................................ <br /> PHONE PHONE <br /> a <br /> .......... <br />........................................................................................... .................................................................................. <br /> PLUMBER WELL DRILLER � � • <br /> 0 <br /> .......... <br />........................................................................................... .. .............................................................................. _. . <br /> v <br /> ADDRESS AD.. DRESS n o <br /> r <br />........................................................................................... ................................................... ....................................... o .: <br /> PHONE PHONE Z \ <br /> DESCRIPTION 4. SanitaryFacilities: 0 0 0 <br /> 1. Work: 2. New Building Details No. Bathrooms <br /> o <br /> New Building ,......... Type of Construction: No. Bedrooms .......... z <br /> Addition . ........ .................................................... Septic Tank Size Gals. .......... <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... <br /> Filling/Grading ..,,,,,,,, Height............. Stories ............... 4a. Absorption Field Site: i <br /> Moving .......... Area ........................................... Soil Type .................................... <br /> Mobile Home .......... Slope .......................................... <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Well Dry Well <br /> ,......... home,garage, motel, etc.) 'I E <br /> SubdivisionSeepage Trench ..... <br /> ..... <br /> .l.�.. .................................................... .. <br /> Camping Unit .......... Privy .......... <br /> .................................................... <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 road i C. <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- o- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING f ��-, <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. )a i o <br />---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: ,I <br /> ................ ft. x .............. ft. . ............................... sq. ft. ............................................................................... - E <br /> v N o <br /> ea <br /> � 9 Yo <br /> t <br /> Z <br /> a <br /> 4 I <br /> 7J r V m m Z <br /> C <br /> C N <br /> Vl G `f m C m <br /> o '^ n a <br /> m <br /> z o o a 77 <br /> o � <br /> c ' <br /> 1 0 � <br /> vti o <br /> Signature of Owner or Agent ' Date — <br /> S <br /> X : M w�L> o <br /> Remarks........... .. ....!!u ... ....�1%.".. ........................................................................................................................ m <br /> m <br /> F» <br /> ........................................................................................................:.... ...r..........................,................................... \ <br /> �•._• . :amu................. <br /> Inspection Date ....................................... .�....:.............. ......:........... ....... m <br /> Zoning Administrator y ✓ 1` $ 8 $ $ $ 8 N <br /> NOTE: A preliminary site inspection must be made and site approval granted on all str,clures 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 tie made without approval roval of the Zoning Administratol . <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />