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Burnett County Office of Zoning Administrator o/ o <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 •� m o <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use c <br /> / W �J^ p <br /> /%..Q.N", lel✓.. .. �. . .�/.1..... . .... . ................ cousin. 3 0. <br /> Ordinance, Sanitation Code, and with all other applicable Count OCONTRACTOR or SU RVEV OR aor AGENThe State of Wisconsin <br /> and 9 <br /> OWNER (please print) <br /> 7./. .. ?. .y............."A fit f-47/i.... ...... . .............................................................................. a 7 <br /> ADDRESS ADDRESS <br /> r. <br /> En. �A.... ' <br /> .... ... ....sry ........... ................................................................................... <br /> ADDRESS / ADDRESS v <br /> PHONE PHONF. Pi <br /> ....................................................................................... . <br /> .... .. ... .. . ... ...... .... .�_ <br /> PLUMBER .. . . . .. . ............................................................. <br /> E <br /> WELL DRILLER <br /> ......................................... . ..... ..... ... ....... . .... <br /> .. ... ... . .. . . ........... <br /> ADDRESS � �� � <br /> ADD���RESS� .................................................................:.......... <br /> n o UJ <br /> PHONEPHON..E................................................................................ <br /> DESCRIPTION 4. Sanitary Facilities: (Z ° o <br /> 1. Work: 2. New Building Details No. Bathrooms 3 ro <br /> o : <br /> o <br /> New BuildingNo. Bedrooms t <br /> .... ..... Type of Construction: ���������� <br /> Addition ... ..,,.. Septic Tank Size Gals. .......... F : 'J <br /> ................................................. .. <br /> Sanitary .......... Size ...(o...P.. ft. x ..1.2..0 ft. ...••..••. rn : <br /> Filling/Grading .,.,...,,. HeigYj ..%,'I.�. Stories ...../........ 4a. Absorption Field Site: 7S E <br /> Moving .......... Area Soil Type ................................. .. :� � <br /> Mobile Home .......... ........................................... Slope .� <br /> o <br /> Privy ......,,,, 3. Use (describe exactly, 1 -family Pero. Rate .................................... o E I <br /> Well ... ...... home,garage, motel, etc.) Dry Well .......... <br /> 1b :"i <br /> Subdivision ,,.,,.,.., p Seepage Trench A,, ^S <br /> .....!r�...-.....��Xd fl.�....... :O <br /> Camping Unit— Privy ,,,,,,,,,, H � <br /> .......... <br /> .. .... ... 7 C <br /> .. .... ..... . ... .. . ...... Seepage Bed ...,. <br /> ---- -- <br /> v N <br /> Location of proposed structures and existing structures well sewage systems roads etc. should he sketched n f A Include road <br /> setback, side and back yard dimension and location and setback from ail bodies of water. If property is located at a highway I rter- <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. O o <br /> 5. Lot S----_—-----___----_..-----------------------------._.-----._.------ ___-- <br /> 5. Lot Size //`` Fi A. 6. Locatiop: N c <br /> ...�G.Q..r. ft. x ..t ft. <br /> .......... i, E <br /> 0 to <br /> /H-7-,vo <br /> e/-f 11--i <br /> N <br /> 0 0 <br /> C1 <br /> 0 <br /> T <br /> W <br /> kh <br /> vAle IeG <br /> 1r Vi tri. �3� Se <br /> /va / (�l/✓ Q�� 7e�e fo..e eow�es�..�.-.. (/ � � 0 - M � �a W Z <br /> �o �'nbr(r C /14 / <br /> S GIC <br /> 7 0 on <br /> 5 <br /> LV o i _ <br /> cN 33 <br /> z <br /> ... .. ... ... .................... .. 7.-.......1..-.. ... o_ p <br /> Signgfur e of Ownet or A.en <br /> t Date ! ° . C <br /> A [Ef q2 0 oKff/4o✓ (�_ o x �o <br /> RemasO/1UU/ lb :. . . .... ..... ...........�.......................................... : ......u... .......................T.....S.....s.......... <br /> ......�..'.......................... <br /> vll.a� . � . .. . .. S . .... . ..........e .. . . . P <br /> N1V � <br /> .... <br /> Inspection Date ....................................... ........ .. .. .. <br /> II <br /> N N r m N m <br /> ...... .. .. . . .. m <br /> Zoning Admin rotor 0. 000 yc0 C <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 be attached to <br /> this application before a permit will be Issued. Do not purchase or install a septic tank, do any plus ing 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 mule without approval of the Zr ring Administiatot. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL. INSPECTED BY THIS OFFICE AND APPROVED. <br />