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Burnett County Office of Zoning Administrator - <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT 3• UJ <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and M i-J <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the n O <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 �Jll <br /> regulationsof the Stateof Wisconsin. »_ a <br /> s w <br /> M <br /> .d�. n..'. n. . rr�..... :. i... ..................... I: . .... .1... . ........................ ...... nom' <br /> R (Please Prin (� CONTRAC OR or SURVEYOR or AGENT ; <br /> :...a ..t � ................ �G ....L,.....` . . . ....1 �. ................ ....... d <br /> A RESS _ r ADD _S <br /> ,���/gyp/' 1/� <br /> ..\ Sly... ....�LU..l..•.....m.1.::1.t��./.�....................... .ADDR�.�..tL:C.4f..7...p...r.): ...1.!. ��/..1............. ....... I ?'y <br /> ADD ESS <br /> ........................................................................................... .................................................................................... ....... ? '. <br /> PHONE PHONE <br /> .. . ...... ............................................................................... . . . ............................................................................. ....... <br /> PLUMBER WELL DRILLER <br /> p :3 <br /> . . . ................................................................................ ..A........................................................................ <br /> .......... ....... —. <br /> ADDRESS DDRESS n C <br /> c <br /> o <br /> ........................................................................................... .................................................................................... ....... .: <br /> PHONE PHONE Z „°, r ;7 <br /> DESCRIPTION 4. Sanitary Facilities: ° S ° `--iCi <br /> No. Bathrooms 'a `•', <br /> 1. Work: 2. New Building " ”""' <br /> Details o i <br /> New Building Type of Construction: No. Bedrooms .. ....... <br /> Septic Tank Size Gals. .. ....... i <br /> Sanitary .......... Size .............. ft. x .............. ft. .. ....... <br /> Filling/Gradingg 4a. Absorption Field Site: <br /> .......... Hei ht............. Stories ............... <br /> Moving .......... Area ......................................... Soil Type .................................... r <br /> Mobile Home .......... Slope .......................................... m .. <br /> Privy .......... 3. Use (describe exactly,'1 •family Perc. Rate .......................... ........ <br /> Well home,garage,motel, etc.) Dry Well ..... 1 <br /> Subdivision Seepage Trench .... c <br /> Camping Unit .................................................... Privy ..... . <br /> Seepage Bed .. I <br /> Location of proposed structures and existing structures well sewage systems, roads, etc. should be sketched in Fig. A. - —L--' I F <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is loca ed at r <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersec ion. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. __ tl o ; <br /> _______________________________________________ . <br /> 5. Lot Size: Fig. A. 6. Location: i 1 � <br /> ................ ft. x .............. ft. — sq.ft. ....... (/1 <br /> ............................... ..................................................................... . <br /> y-aa.� N O <br /> I / <br /> O 0 <br /> _7 <br /> ���� 33 <br /> Vo 1 e I� ° <br /> t :1. <br /> ry' T <br /> Z <br /> .� o <br /> ` 1 M <br /> 71 m rn <br /> c 71 m r n ca cm <br /> w <br /> Zgm o <br /> i5n <br /> n <br /> 20 m <br /> x A : m <br /> ........................................................................... ...................................... <br /> Signature of Owner or Agent Date oo <br /> T N <br /> Remarks � <br /> m •• <br /> ......................................................................................................... .. ....................... . . .. ............. �J : o 'n <br /> �1/�/rJ NW " - <br /> N <br /> Inspection Date ....................................... .. . 7.(.b`.GY..... ...../kW. .. .{ N (T N 00 O N m <br /> Zoning Administ for <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities 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 ben issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans oi specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE ANDA PROVED. <br />