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Burnett County Office of Zoning AdministrIttor W �/ e <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 land0 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the n F <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and <br /> regulations of the State of Wisconsin. <br /> ..........,. . N <br /> ................................ .............................................1...... d , <br /> OWNER lPease rint) CONTRACTOR or SURVEYOR or AGENT •- <br /> 4 <br /> 7.3..1......:x.. .y.......:5':............................... .....................................................................................1...... d <br /> ADDRESS ADDRESS <br /> �.up�r. f�c . .....�1..................SY.tS ............ ............................................................4........................li <br /> ADDRESSr ADDRESS i <br /> 1.1. ..::..... q�..l�.y ..l.................................. .....................................................................................i...... <br /> PHONEPHONE <br /> PLUMBER. ............................................................................... ..WELL...... <br /> ....DRILLER........... .............................................................:I....... <br /> ........................................................................... . . ...... . .................................... ... <br /> .............. ..................L...... o <br /> ADDRESS ADDRESS m .0 <br /> 0 <br /> ° o <br /> .......... <br /> ... . . .................................................................... . . .................................................................................. <br /> `- <br /> PHONE PHONE...... .. 0 '� <br /> Z r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details c <br /> New Building .... Type Type of Construlction: No. Bedrooms ..�....... E R <br /> Addition .......KQ. S—............ Septic Tank Size Gals. <br /> Sanitary �y... ..�....... . <br /> .......... Size ...../..�... ft. x ........ .. ft. <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Area Soil Type ............................�....... <br /> Slope ° <br /> Mobile Home .......... .................................. ....... .. <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ...........................j....... o i E E <br /> ° <br /> Well .....,.,,, home,garage, motel,etc.) Dry Well — <br /> {....... <br /> Subdivision ..f c,;-vh,�, Seepage Trench ..1....... o <br /> . `` �LCe�.tn.......... <br /> Camping Unit ,\ol Privy .. <br /> .......... ................A .f.............. .......... 1....... <br /> Seepage Bed <br /> ------------------------------------------------------------ <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. ��1^ C <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. `— <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. 10' <br /> -------------------------- -- -- <br /> --- -------------- ---------------1— \ i <br /> 5. Lot Size: Fig. A. 6. Location: <br /> 0 <br /> 0 <br /> INTO 0 <br /> p <br /> n <br /> Alo <br /> ul S � L TO <br /> wry <br /> a <br /> i <br /> � ! dV \ <br /> i 1 mtnvcnr Dmmy <br /> �U m ane nm nny <br /> S ov0 : m '� nD : <br /> y n _ � <br /> 1 0 c O <br /> n O . <br /> XLYI. 7J / ^ o <br /> ............... C../........ <br /> Sign ura of er or Agent Date ] o <br /> Remarks ... ... }.iSTQR�........ .:".. ...... {.Q.3 a�S..9..........................laC..X.... ..../...LIS E n....C!d?A��'. <br /> on <br /> ... /.:%y/ . ............:.{. � .......::S.S .......................c c? .... i.....ra.o.f' .. o <br /> f?G.� .. ...5!1. ..../ .. �. .. ..0a.I. ................................ . . s <br /> M <br /> InspectionDate ....................................... ........... ..... ... .. . . ... .... .. .... N m <br /> Zon ng Adminis for g g g g f/1 <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary fa ilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this application before a permit will <br /> be issued. Do not purchase or install a septic tank, do any plumbing or start any building until a permit has been issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />