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Burnett County Office of Zoning Administrator c <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 v 1 <br /> regulations of the State of Wisconsin. a ' <br /> a A10A,� Y D. — bi <br /> XE.AIIftEThf.....� w.a... .... au..1:. .... .z^ ►�s......��r,lf�..r.A. ....�...... a <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT <br /> ADDRESS .ADRE�SS/t/�N..1'i...8..1t.RG ..G(Jt.s.�.... ...... a <br /> ................................�5 0.s.......... ..................................................................................... ...... <br /> ADDRESS ADDRESS <br /> G.1. .-.Y..SI..-..2..Y(N..$..................................... ... ................................................................................. <br /> PHONE PHONE <br /> ........................................................................................... .WELL....... D..... ...RIL.. L...ER........—............................................................ <br /> PLUMBER <br /> ........................................................................................... . ......................................................................................... .v <br /> ADDRESS ADDRES.. S � C <br /> c 7. < <br /> ........... <br /> ........................................................................................... ........NE......................................................................... o <br /> PHONE PHO ' <br /> DESCRIPTION 4. Sanitary Facilities: ' ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms <br /> + <br /> i o <br /> New Building No. Bedrooms " i <br /> z <br /> .......... TYpe ofnstr�IDn: i.Septic Tank Size Gals. .......Addition ........... ( <br /> ..X... (! i7,l� <br /> Sanitary Size .............. ft. x ft. ..�....... <br /> Filling/Grading ......••.. Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... Soil Type ............................ ....... r <br /> Mobile HomeSlope ° <br /> Privy .......... 3. Use (describe exactly,'1 -family Perc. Rate ........................... ....... 0 <br /> Well .......... home, arage, motel, etc.) y <br /> Dr Well .. ....... � <br /> Subdivision ,,,,.,,,,. I l Seepage Trench .. ....... o <br /> a....�A.M..... .r........... <br /> Priv ' <br /> Camping Unit s, 1 p�V ,� Y .. ....... ((```` - <br /> .......... ..... .Q...... .................... .. :W <br /> Seepage Bed .. ....... --�. <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. R C <br /> Include road setback,side and backyard dimension and location and setback from all bodies of water. If property is local d at .� ' <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. = <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. j o <br /> ___________________________________________________________________ _ i <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ....�.Q..4`).... ft. x .�a:.�..... ft. . ....1.,�,.3.c?4�......... sq.ft. ................N.11a.(.I�RQ e.b.'••!:.K .I........................... <br /> S6'GT+69N 3e VOv1't-O rS �/�Fi Sr <br /> N 0 <br /> NVQ Sl'JCF.. l ioec,\ r 'VS <br /> ef--- IOJ <br /> do <br /> t42e1 GvvrL0nLf� Izi.y : <br /> j ' Qt4 Ta-rtDE�,pK�} Q Z <br /> d- X03,0 l30 Oo <br /> M1^ <br /> 'r m wvinr Dcomy <br /> m �n� Pnm as 9 <br /> O N O m b <br /> O f0- Z D 1 <br /> 60 <br /> c <br /> M <br /> Signature of Owner Agent Date o <br /> Remarks ....................................................................................................................................................................4.... = _ <br /> y . <br /> t�.EhI.PaRS(f..�rXiFS•T.. <br /> f.-M. W*x.ct#.wtS <br /> .......1`.... <br /> 0 0 <br /> ........�4.��.vvie....D.,,.�...Tn......................................................... .... ..............A <br /> ,.. <br /> Inspection Date ....................................... !L? ).... /L✓ .............,I. In <br /> 365 O N (T O N <br /> Zini for g g g g g 0) <br /> NOTE: A preliminary site inspection must be made and siteiapproval granted on all structures involving sanitary fa it sties before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this appI cation 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 bee issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or pecifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND AP ROVED. <br />