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-e7 c »� <br /> Burnett County Office of Zoning Administ'•ator OW 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and looted as < Hshown herein The ' <br /> Ordinance, Sam[ationCode, and with all other applicable oin <br /> and the laws andregulations <br /> of the Burnett County La d Use <br /> undersigned9requirements <br /> Q � County ��/e9 ions of the State of Wis ons... C, <br /> O <br /> 0 R(please <br /> #print) / CONTRACTOR or SURVEYOR or AGENT a '` <br /> a <br /> A RE S � ADDRESS �7 <br /> . oJ.....621' l .... 1......................................... ................................................................................... °Q a <br /> A ESSII I ADDRESS <br /> Oom n�fl41c� <br /> ............... .. . .��. 1....................... ...................................................................... .......... X <br /> PHONE PHONE � �^ <br /> ........................................................................................... ...........DR....I..LLE..'ER......................................................... .......... <br /> PLUMBER WELL <br /> O <br /> ADDRESS ADDRESS � o i(d <br /> n <br /> ...... ..... O <br /> ........................................................................................... ........................................................................... ..... .i <br /> PHONE PHONE Z r :O <br /> DESCRIPTION 4. Sanitary Facilities: / ° o <br /> 1. Work: No. Bathrooms ! ' <br /> 2. New Building Details <br /> New Building No. Bedrooms ! ti <br /> ,,,,,..... Type of Construction: <br /> Add]doo p Septic Tank Size Gals. ✓. .. � i <br /> Sanitary Size .' ....... ft. x ...,a.v. ft. <br /> Filling/Grading .......... Height............. Stories .......... 4a. Absorption Field Site: <br /> Moving ........ <br /> Soil Type ......................... .. ` o i <br /> .......... Area ......................................... <br /> Mobile Home Slope ............................... .......... <br /> Privy .......... 3. Use (describe exactly, 1 -family Pere. Rate ................................... 7 l <br /> Well .......... home,gar e, mot 1, tc ) Dry Well ........ l Z <br /> Subdivision Jg,'gL Seepage Trench ........ .6a, <br /> .......... . .... ...... .�'".� .. <br /> Camping Unit .......... Privy ................. ................................ q <br /> C <br /> Seepage Bed .......... <br /> -------------- --------- --- LJ rn Z� I <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc.,should be sketched in Fig. A. Inclu An road Q � � 4 <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- r 2 <br /> section, show the intersecting highways ad the setbacks required along them and at the Intersection_ CLEARLY LABEL EX STING <br /> 0 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS o <br /> 5. Lot Size: /� lL-O"t-" " Fig. A. 6. LocatiP- r <br /> SS}}99 ? m <br /> ................ ft. x .............. ft. — ............................... sq. ft. ISS 0!3 Mtl lJe , a .. o <br /> Co F y, to <br /> d n <br /> N o' <br /> 0 <br /> 3 <br /> -171 <br /> � W <br /> O <br /> s <br /> Jar 0 <br /> Do`3`l sec 0 E <br /> �vt m z <br /> C .` m a m <br /> -o <br /> ba; m < n _ R <br /> p 00 n <br /> A _ < <br /> Qj,O <br /> ..�,^/.7../tel../�C�'if,�f,T,,,,✓�;..\.F........................' ................................ .... � O � � : C <br /> S'gn/ ature of Owner or Agent Date - <br /> X a <br /> Remarks ................................................................................................................................................................ ........ m n <br /> C <br /> 06EC � ................... <br /> ....... 1 � <br /> II <br /> .............. .............................................................................................. .... ..... <br /> ...... .. . . ....... <br /> ......................... <br /> n <br /> Inspection Date ....................................... ..... .... .. ... . . ...... . . ............. ........ t; u, v, o u, o u, R <br /> Zoning A ministratcr g o 0 0 0 co <br /> NOTE. A preliminary site Inspection must be made and site approval granted on all structures nvolving sanitary facilitie. <br /> before construction can begin. In the case of sewerage disposal systems, a copy A4of the percolatl est must be attached to <br /> this application before a permit will be issued. Do not purchase or install a septic tank, do any p t ibing or start any build- <br /> ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the i formation conveyed herr <br /> with is found to exist. Changes in plans or specifications shall not be made without approval of the Zoning Adrninistr atoi . <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />