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Burnett County Office of Zoning Administrator V o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. = jt <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as ,n iu\ <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m XuA1 <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 0. <br /> 8fit �-Ol1 U L/ � 64ati o H <br /> . ...................... ........................ ................................................................... <br /> ...... ........... .. <br /> OWNER (Pleasprint) CONTRACTOR or SURVEYOR or AGENT a <br /> f d toP. 0. B0 . . ................ d \� <br /> ...0.. .......1�, ..... ...1in��............................... .......................... .....19......................... <br /> AD SS ADDRESS <br /> uxnlO.l.l .../.Wn..n..... s3 ............. ....... ....w> r>7............................ <br /> ADDRESS ADDRESS l �� <br /> G/Z- %' .-3 66 <br /> ......................................................... ............................................................................................ <br /> PHONE ......................................... PHONE :"ts <br /> .................................................. . . . ..................................................................................... �\ <br /> PLUMBER WELL DRILLER rte` <br /> ........................................................................................... ............................................................................................ <br /> ADDRESS ADDRESS i o <br /> ^_. C <br /> .... .. . . .........................................Y....................................... o <br /> PHONE.................................................................. <br /> .. ... .. ....g PHONE...... .. 0 .\ <br /> 0 <br /> r , <br /> vp <br /> DESCRIPTION 4. Sanitary Facilities: a; � .+ <br /> 1. Work: 2. New Building Details No. Bathrooms .......... 1 i o <br /> New Building No. Bedrooms <br /> Type of Construction: """"" <br /> Additlo JC./Y.tin OX� Septic Tank Size Gals. f'• .. <br /> +� 1: <br /> Sanitary .......... Size ......LN.... ft. x o2 � ft. """"" <br /> Fill l ng f Grading ,,,,...... Height............. Stories ............... 4a. Absorption Field Site: <br /> . �! r �(J <br /> Moving .......... Area ........................................... Soil Type ...................... ............. <br /> o <br /> Mobile Home .......... Slope .......................................... N �+ <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... :�,�, <br /> Dry Well U <br /> Well .......... home,garage, motel, etc.) "'••""' ' <br /> Subdivision . �....... tYudSeepage Trench .......... <br /> ... . ...� <br /> p Priv <br /> Camping Unit {S�.hJ1 (Jrj,�'j, y <br /> .......... . ... . . ........................ Seepage Bed o <br /> Location of proposed structures and existing structures, well, sewage systems, roads etc.,should be sketched in Fig. A. Include road 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- W a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING O ,� <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. L ation: in <br /> a d00 !?tmtzn*G0-' ��..................................... v <br /> ................ ft. x .............. ft. — ........J..................... sq.ft. :3 <br /> D✓1 7 :C cn <br /> 't0 NwXh 2 <br /> �s WEot� I a 0 <br /> I�ot� copy Lot 3 rne �eu"*1 <br /> �Cim P wov(al d� 1tftE id al d arK�,y + d» - <br /> J <br /> \ u o <br /> J � <br /> � t1 <br /> I <br /> a <br /> Z <br /> 0 <br /> d <br /> ( m <br /> - W . <br /> I <br /> v rn < m � e'o m <br /> L-10 ' t ow. 0 lfwwl .O� L , o a �o <br /> t-l`°-.. -e y is fn 64ei f \0� 0 3 <br /> .�--- .W <br /> pm <br /> ................... <br /> = <br /> Signature of Owner or Agent Date <br /> X <br /> Remarks ......................................................................................................................................................................... m m <br /> m <br /> ............................................................................................................ ...... ................ .. T <br /> .......... .................................... <br /> e: <br /> ...................... <br /> m <br /> InspectionDate ....................................... ...... . ................ .....9........ ............. en <br /> Zonin Ad Inistrator 8 8 8 8 8 8 in <br /> NOTE: A preliminary site inspection must be made d site approval granted on all structures 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 he made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />