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Burnett County Office of Zoning Administrator o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT <br /> 3 <br /> W1 o <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as m �` <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 0- <br /> �ert7.-f0,y l�r1Pf h �.1 ....... . ..�.1�.� ...................... M <br /> {;d/I ............................................... ...... <br /> OWN R (please priht) <br /> / CO ACT9R or SUR E OR or AGENT <br /> ��C?.l ►n......./�.ah.� . . . . .L............�e.1<.............�..�........................... <br /> ADD ESS ADDRESS / m ^ •� <br /> ��/ G/jam/) //� / /, ) (` r <br /> / ll ,.[!..a:...�........I.'...�.�................� ��� 'ADDRE�r.. ...S.. S.r. ........f '..L7................... :'\1 <br /> t /.. <br /> ADDRESS <br /> 6.1.a....-. .... .. .1.......... ............... ...... 6.6.........v. I3..�.......................................... <br /> PHONE PHONE <br /> .. ........................................................................................ <br /> . .......................................................................................... \ <br /> PLUMBER WELL DRILLER <br /> ........ . .......................................................................................... <br /> ....... ............................................................................ <br /> ADDRESS ADDRESS n o <br /> . . . ............................................................. . .......................................................................................... <br /> o <br /> . .. .... <br /> PHONE PHONE o a o <br /> DESCRIPTION 4. Sanitary Facilities: <br /> 1. Work: 2. New Building Details No. Bathrooms ••• • ' <br /> 0 <br /> New Building Ty e of nstructl <br /> No. Bedrooms ......••.. i <br /> Septic Tank Size Gals. <br /> Addition .......... ..�et. .. .... ...5�..... .n.. ... r f �.; <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... v <br /> FillingfGrading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> SoilType ............................. ...... <br /> MovingArea ............................ .............. i m <br /> Slope <br /> Mobile Home .......... ' <br /> Privy Pere. Rate ................................... <br /> 3. Use (describe exactly, 1 family n: <br /> ""••" Dry Well k <br /> wellho e,garage, motel, etc.) ' <br /> """"'• y a/ Seepage Trench 'q <br /> Subdivision .......... :eP—r.....��..k........... . t . <br /> ..^,, Privy .......... <br /> Camping Unit .......... .CC.l.c.G.kl.......�0.r.�.�.... <br /> Seepage Bed .......... � <br /> __ <br /> Up <br /> Location of proposed structures and existing structures,well, sewage systems, roads,etc., should be sketched in Fig. A. Include road t <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property Is located at a highway inter �. <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. f` o <br /> ------------------------------------------------- <br /> 5. Lot ize: Fig. A. 6. Location: ,p vn <br /> 'e,o.�...... "no�....... .:......... <br /> ...... /.0 <br /> �. .a... ft. x .�.�.L!�6ft. — .dQ/...3��......... s9.ft. <br /> �e �oc-�� N K, o <br /> � y o <br /> a, <br /> . o <br /> M rp <br /> �.Lx2V 0 <br /> IeC <br /> 9 (l1 < m m m <br /> 3 <br /> i,�iJ6' <br /> . . . ...... ......... ........ .......................... . <br /> Siwn or" g nt ... .... Date X <br /> � : m <br /> Remarks ................................... O <br /> m <br /> .................... ....................................................................... rr <br /> ............ ....... .............................................I............... 1c' <br /> .. ... <br /> GO.� :.....7.. GLeL`'�? U88888tom/ <br /> Inspection Date ....................................... . ..... . .. ........................ 8 <br /> Zoning Administrator " ' <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facllitin: <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 riot 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 mane without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />