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cl—" C"C-� ' <br /> Burnett County Office of Zoning Administrator W - 0 <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 rn '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 /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 <br /> a 0 <br /> ..... . ...... .... .. _ <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT M <br /> S.ErG�..........�!rc.C,44............. ........ CL <br /> ADDRESS ADDRESS � <br /> (....e".S..TA.,7.ES........:t<.!<;. c..../9 '........................................................................................ <br /> ADDRESS ADDRESS <br /> ........................................ . .................................................................................. <br /> PHONE PHONE.. X16 <br /> •i ........... .C.re ........................ ............................................................................................ <br /> PLUMBER WELL DRILLER <br /> I�.T. ......A.......... 5'lf4�t4l ..., k .................... v <br /> ..........................................•..•..............................•............... 1 <br /> ADDRESS ADDRESS <br /> o <br /> to.�c :.r7. ..U.............................................. ......................................................................................... o <br /> PHONE PHONE <br /> DESCRIPTION 0 H 0 <br /> 4. Sanitary Facilities: � o ° i <br /> v <br /> 1. Work: 2. New Building Details No. Bathrooms �'� o i <br /> New Buildin No. Bedrooms <br /> g ........., Type of Construction: <br /> Addition .......... .................................................... Septic Tank Size Gals. <br /> Sanitary ......••-• 'v <br /> ...�� Size .t........... ft.x ..s ......... ft. �(, i <br /> Filling ,,.,,,.,,, Height............. Stories ............... 4a. Absorption Field Site: "\ • <br /> MovingSoil Type ...... .... <br /> .......... Area ........................................... YP rf.,t�14C.�Q.......... � o <br /> Grading .......... Slope .......................................... S,, <br /> a € <br /> Mobile Home ,..,..,... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Privy home,garag ,motel,etc.) Dry Well <br /> Well .......... ! Seepage Trench .......... <br /> SubdivisionPriv <br /> ..............................I.................... <br /> Seepage Bed--------------------------------------------- <br /> ---------------------- — <br /> --- ' E� <br /> Location of proposed structures and existing structures, well,sewage systems,roads,etc., should be sketched in Fig. A. Include road c- t- c <br /> s <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- � o. <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. 6 = <br /> C O <br /> ---------------------------------------------------------------------- r' <br /> 5. Lot Size: g, 1-140 4-f Fig, A. 6. Location: C k <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... _ <br /> m <br /> c <br /> N O <br /> O <br /> 7 <br /> v W <br /> 0 <br /> f <br /> s <br /> -n <br /> Z <br /> o <br /> N <br /> m <br /> ?� :� <br /> G�in E jc B Z` �'ec%< 7 i N C t fG't` <br /> " A, -0/a�,C /y M to t- -�- to N <br /> M C N n. rp d <br /> a o, a <br /> Z oo m < m <br /> o �. 3 <br /> cn rc � <br /> ..... . .U�.... .k.6 ...... .. .rTl...�A. <br /> M <br /> Signat rine <br /> o-`f` <br /> o C <br /> r or Agent Date <br /> S O e X i i 70 <br /> Remarks ... -9.0!7.... -n <br /> ......................................................................................................... <br /> m A <br /> c , <br /> .....................:.................................................................................. ... . .............. <br /> Inspection Date .l5?.. .:........................... i�.� ..... .......................... Io 0 0 0 0 Lc m <br /> Zoning A inistrator E i o 0 0 o o CO <br /> CD oom <br /> TOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> efore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> lis application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> Ig until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> lith is found to exist. Changes in plans or specifications shall not he made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />