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Burnett County Office of Zoning Administrator 3 o o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 o b <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use <br /> Ordinance, Sanitation Code, and with all applicable County Ordinances and the laws and regulations of the State of Wisconsin, :F_ c, <br /> F./../../ TT <br /> OWNER (please pnn CONTRACTOR or SURVEYOR or AGENT a n <br /> ,�,f3.nloa [ <br /> o�f..... ... 02.. ./A... .. . <br /> ADDRESS ADDRESS <br /> ...L ,.�1Zrt�. s�� ...................................................................................... <br /> ADDRESS /woQk.. DDRESS <br /> S.......................................................................................... b <br /> . ... _3a . .....3yH.-.Sy.. M <br /> PHONEHONE .................................................................... � Z <br /> ........................................................................................... . . . ... . . . . . <br /> PLUMBER WELL DRILLER <br /> ........................................................................................... .AD......D.RES... ................................................................................. <br /> ADDRESS S n o <br /> PHO...............— ........................................................................ . . . . .......................................... ....................................... <br /> NE PHONE z � � <br /> DESCRIPTION 4. SanitaryFacilities: ° o <br /> 1. Work: No. Bathrooms 0... v <br /> 2. New Building Details "" o <br /> New BuildingpI <br /> Type of ConsFruction: No. Bedrooms ..../..... t pI O <br /> Addition .... .. ...P.'D./ .��Q77:",j'w.....................�.tt.......... Se Ptic Tank Size Gals. .... <br /> Sanitary .......... Size .......9.... ft. x ..,��..Z F1.. ft. ...... <br /> C <br /> Filling/Grading Height............. Stories ............... 4a. Absorption Field Site:NA <br /> Soil Type ...................................Moving .......... red ........................... ............... . na <br /> i <br /> Mobile Home Slope .......................................... �* <br /> .......... <br /> Privy .......... 3. Use (describe exactly, 1 -family Pere. Rate ................................... f i <br /> Well .......... home, garage, motel, etc.) Dry Well .......... <br /> Subdivision ... Seepage Trench .......... oQ <br /> ....... .................................................... <br /> Camping Unit .......... .................................................... Privy .......... <br /> Seepage Bed .......... <br /> ------------------------------------------------------ \ c <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be, sketched in Fig_ A- Include road <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 ----- STRUCTURES AND ADDITIONS <br /> -- <br /> 5. <br /> 5. Lot Size: Fig. A. 6. Location: <br /> //// / <br /> ....5o... ft. x .75� ft. — .�.�.t.�S )...t. sq. ft. ............................................................................... <br /> le.eO. F.2rY L>Al <br /> M to <br /> o n <br /> p N O <br /> C o <br /> A 0 <br /> A LU <br /> f o 2 Z <br /> 0 3a` °� O <br /> g I G <br /> t <br /> _ — q <br /> \ n <br /> NQ � n c <br /> m d n`< = ry a <br /> m <br /> �� a <br /> o <br /> 3 <br /> P,poPF,ery �IN� - <br /> a � <br /> o � <br /> ....... ..... .................. ..... .. ...... .. .. ...... ...................................... p <br /> Signatur of Owner or Agent Date — <br /> X 31 <br /> Remarks ......................................................................................................................................................................... m 0 <br /> : <br /> us <br /> ...........—...............................................................................................................................................................I.......... — <br /> � n <br /> Inspection Date ....................................... .. ...." u�o\N m <br /> Z Ing Administrator : : 8 0 0 8 0 VJ <br /> NOTE: A preliminary site inspection must be made and 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 lie 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 the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />