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Burnett County Office of Zoning Administri flor <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 yyT <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements o the c <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 ; <br /> regulations of the State of Wisconsin. _ a <br /> a4. A.�.. .......... .. ST.A. .N//'...... ................,�'� .�.�`::............................................. ....... <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT <br /> ..N.... ........ ..... . ................................. .................................................................................... ....... <br /> ADDRESS ADDRESS m •-"� <br /> he c _Z LA1?. .ZL /s'c / <br /> ADDRESS ...... �........................ . ADDRESS <br /> ?�. .:..1.. -. .%. .z ........................... .................................................................................... ....... l` <br /> PHONE PHONE ; '-•�� <br /> PLUMBER WELL DRILLER <br /> . R <br /> .......................................................................................... .ADD.......RES—E'S-..................................................................... ........ _. <br /> ADDRESS S n O...... ....... <br /> ........................................................................................... . . ................................................................. . <br /> PHONE PHONE......... 0 r, r <br /> DESCRIPTION 4. Sanitary Facilities: ° o °» <br /> Bathrooms oo <br /> i. Work: 2. New Building Details No. •"..... <br /> � o <br /> New Building dwJ Type of Construction: _ No. Bedrooms . ........ , <br /> Addhion W ,gO•••,-F1.�7 ........ .. Septic Tank Size Gals. . ........ ` \j <br /> Sanitary Size .og.!V. ft. . ........ <br /> Filling/Grading .......... Height............. Stories ..� 4a. Absorption Field Site: <br /> ........... <br /> SoilType ................... ....... ........ <br /> Moving .......... Area ......................................... r i <br /> Mobile Home ....... Slope ................................. ........ <br /> .. y <br /> Privy Perc. Rate .......................... ........ <br /> ,,,,,.... 3. Use describe exactly,'i -family <br /> - Dry Well ........ <br /> Well .......•.. home,garage, motel, etc.) N Z <br /> " ° <br /> Seepage Trench . ........ I t <br /> Subdivision .......... .../.�. .... �� / ! ./�. !` Privy ,T!/ <br /> Camping Unit .......... ........./ .....� c- <br /> Seepage Bed . ........ 1" n; <br /> Location of proposed structures and yard <br /> structures well sewage systems, roads, etc., should be sketched in F g. A. 4,s <br /> Include road setback,side and back and dimension and location and setback from all bodies of water. If property is loc ted at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the interne tion. \ _ <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. y`; <br /> __________________ ____ __-----___ _------_ --- i <br /> M . . <br /> 5. Lot Size: Fig. A. 6. Location: (j, <br /> ................ ft. x .............. ft. — Afl.,X tt; P'-E,1 sq.ft. <br /> .. rl <br /> o <br /> J <br /> rU '� <br /> T <br /> N T <br /> m �J <br /> 0 <br /> O <br /> a <br /> J <br /> b <br /> m <br /> L� <br /> M (n rn r- D W m 'a <br /> (p c M. N m 0 c c <br /> � <br /> n o < J J o . rn <br /> m a•< � am nag <br /> D 1 <br /> ° N J o, a : A <br /> [na O : D <br /> � + . ^ . <br /> ° <br /> ... .......... . ....... ... �...... . ../����r�:. f o <br /> Signature of Owner or Agent Date <br /> VVV T: <br /> Remarks ......... 11 <br /> l ........ . ....................... ...... ......... ..... .. . .. <br /> . <br /> . ........................................................................... . ... ... <br /> _ <br /> o <br /> 0 <br /> Inspection Date ....................................... ..... .lr ...(.:..... .XQ%P�4: ......... ....... N m m <br /> m <br /> Zoning Admini rator o g g $ N <br /> NOTE: A preliminary site inspection must.be made and site app vat granted on all structures Involving sanitary I acilities 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 ank,do any plumbing or start any building until a permit has be Bn issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans c r specifications shall not be <br /> made without approval of the Zoning Adminis'rator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />