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Burnett County Office of Zoning Administrator o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3 � <br /> » O <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 m <br /> Ordinan�QSanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> . .... N /sa - �o <br /> .. ...................... .. ....................... ... . .. .� � ... .... N <br /> DWfsl Efi Iplp,�se prima .. /� . . ............................................... _ <br /> '(1/,�1+ � Rbl{ CONTRACTOR or SURVEYOR or AGENT <br /> .................... ...........b.................................. ............................................................................................ <br /> ..D RE.SS ADDRESS <br /> y? )— � � y ) <br /> (.. . �. Ws...`.......5 �( S! <br /> ............ ................................... ............................................................................................ r <br /> ADDRESS ADDRESS i1 1 <br /> i VO i /n <br /> PHO.................................................................................... .PHON.E................................................................................ <br /> jti <br /> . . .B............. ............................................................... ..... <br /> . ...... <br /> ..... <br /> ........ <br /> ....... <br /> ....... <br /> ........ <br /> ............ <br /> ................................ :r� <br /> PLUMBER WELL DRILLER <br /> O <br /> .................. <br /> ........................................................................................... ........R"ES"............................................................ n o <br /> ADDRESS ADDRESS m <br /> ........................................................................................... .....PHONE............................................................:.......................... Z o ,» <br /> PHONE Li <br /> DESCRIPTION r <br /> 4. Sanitary Facilities: ° o ° ' <br /> 1. Work: 2. New Building Details No. Bathrooms <br /> New Building ....,. .., Type of nstru tion,{, No. Bedrooms .......... <br /> Addition ,,,., <br /> 1,&V Septic Tank Size Gals. .......... <br /> ... ... .. ........ . . i <br /> Sanitary Size .. ��..... ft. x .d.' ft. <br /> FillmgiGrading ,,,,,,,,,, Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area Soil Type .................................... r i <br /> Mobile Home .......... $OPe ................... ...................... ^ 0.. <br /> Privy .......... 3. Use (describe exactly, 1 -family Rare. Rate ................................... (ju <br /> Well home,garage, motel, etc.) Dry Well ...I...... <br /> Subdivision .......... Seepage Trench .......... SU <br /> Camping Unit .......... .................................................... Privy .......... _C: <br /> .................................................. i <br /> Seepage Bed .......... <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road171 <br /> setback, side and back yard dimension and location and setback from all bodies of water. If i <br /> property is located at a highway inter- � d <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. p <br /> — ' <br /> ---- --------------------------------------------__------------__ <br /> 5. Lot Size: A. 6. Location: �, <br /> (� ►4C P� g (� ;d1 <br /> ................ ft. x .............. ft. — ..�..�....................... sq. ft. ............................................................................... ' To <br /> R <br /> N <br /> fi c,,n a o. <br /> :Q0 <br /> o --C <br /> Je i <br /> fat F� o <br /> p,ld as <br /> ztu <br /> qio'-vs-11 n� <br /> pq <br /> n <br /> f <br /> m D _ m <br /> O O O n n <br /> A ro <br /> ........ ../..` ti!^'1.............. ...................................... o p <br /> Signature of Owner <br /> or Agent Date <br /> Remarks ... <.G......:....`......................................................................................................................... T m <br /> .......................................................................................................... �' . . . . . . <br /> .................... ...�.j................ <br /> `.....�./ (� � / N N Ass- N m <br /> Inspection Date . . .: ...../7........ .... ..'1 '...�..a.....'/.'C...:!.u:. . .l.V.. ... U v, oIl <br /> lrn m <br /> Zoning Adminisor l�'v-7-) g o 0 0 0 l/r <br /> NOTE: A prellminary site inspection must be made and site approval granted on all structures inVolVing sanitary tacilitins <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must Ire 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 Adm inistratol . <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />