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Burnett County Office of Zoning Administrator d 1 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT µ' 3 0 <br /> d <br /> o <br /> su <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as < N - L>Q <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Lard Use <br /> Orden nce Sannatio Code, and with all other applicable County Ordinances and the laws and regyylations of the State of Wisc ,i o- <br /> .Q.�a..... ......................... .....&` .k2...... .c3 <br /> .o.�h . . <br /> e .. ............ . ...... _ - , <br /> 01 <br /> OW R (pleaseprint) CONTq TOR or U11V VOR or AGENT <br /> _ VEE / Q <br /> ........................ .....Sr. . ....—.. A. .�. ........ a — <br /> ADDRESS U ADDRESS °f <br /> m ( <br /> ........................................................................................... <br /> ADDRESS . ................................................................................. ........ <br /> ADDRESS <br /> PHONE . ........................... . ................................................................................. ........ ' <br /> ' I <br /> .. . ...... ............................................................................... PHONE <br /> PLUMBER . ................................................................................. ........ <br /> WELL DRILLER � <br /> ADDRESS .................. ... .AD.................................................................................. ........ O <br /> DRESS <br /> n G <br /> n ° <br /> PHONE PHONE <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details <br /> New Building „••,..,,. No. Bedrooms ° <br /> Type of Construction: <br /> Addition ,,.•.•,••• Septic Tank Size Gals. . ........ <br /> ................... .. <br /> Sanitary Size ft. x ft. • .••••••. <br /> Filling/Grading ,,,,,,,,,, Height............. Stories ............... 4a. Absorption Field Site: i <br /> Moving Soil Type ................. <br /> .......... .......................4................... . ........ E <br /> Mobile Home .......... Slope ................................. .+ <br /> Privy .......... 3. Use (describe exactly, 1 -family card. Rate .......................... ........ <br /> Well ....,,,, home,garage, motel, etc.) Dry Well . ........ <br /> Subdivision P g See a e Trench . ........ I i <br /> .................................................... <br /> Camping Unit Privy . ........ <br /> .................................................... Seepage Bed . p <br /> ------------ ------ ..-- •N <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Includ road W � <br /> Q <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- �� a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. �w i `l <br /> 00________________ —_----__—_____------- YJl <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq. ft. ..................................................................... ......... ' <br /> Cs <br /> o <br /> o i <br /> N <br /> 7dr aIn rL <br /> z z <br /> o <br /> ca <br /> M � da dmZ <br /> m a a< = m o m <br /> q N. M m <br /> O ° n <br /> a � 3 <br /> Signature of Owner or Agent Date <br /> X 70 <br /> Remarksm m <br /> .................................................................................................................................................................... .... ° 0 <br /> m <br /> e ' : . . . <br /> ................................................................................ ................... .... .......................... .. .. . .. ............. <br /> ... ... 'II . . . <br /> v � m , Nm <br /> ... <br /> Inspection Date ....................................... ... /../..ly .... ...:....... . ....1 .!.N.. . . .1�,. 8 v, o o <br /> Zoning Administrator 8 8 8p,8 8 5C' m <br /> y <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures in olving sanitary facilities <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation est 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 th Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE NO APPROVED. <br />