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Burnett County r Office of Zoning Administrator A o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT Of <br /> - 3 - o • o <br /> 10 Tr <br /> ' acamoi ADMINISTRATOR:.The i d accusto hereby makes application for a Permit for the work described and learned as - :C <br /> shown herein. The undersigmd agrees that all work shall be done in accedence with the requirements of the Burnett County Land Use <br /> Ordinance, SSanniitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 - :)) <br /> ec <br /> � ...E�`a 5 ........_._ o <br /> ..... . . .. . .... v ..............F�J ... ............................................................................................ » <br /> MINE R (please print) // / CONTRACTOR or SURVEYOR or AGENT .A n <br /> L ly/ <br /> .. .....�f.y. ...-...:,........................N£:..................... .............. .. . <br /> . .............................................................I.......... .. <br /> ADDRESS ADDRESS m ' <br /> S <br /> x . . .........'`i..v,v................... . ...................................................... <br /> . ........ . . <br /> ADDRESS � �/ ADDRESS � ' <br /> .. ....:........_�L.E.:.Xj :.v.:......o'Y.�•`-' Ce/Zl<s .....-.........._......_.._........................._....... ................_... <br /> .... <br /> t >f <br /> PHONE PHONE <br /> ..................:.............................. .............. .. ......... .... .. . .. . ....... . . . ........................ .:. ....................... r <br /> PLUMBER WELL DRILLER <br /> . ...... . . .......................:. O <br /> ADDRESS <br /> ADDRESS On <br /> j '1 <br /> ................. ......................:.................................................. ............................:............................................................... ° <br /> PHONE PHONE - » <br /> DESCRIPTION 4. Sanitary Facilities: <br /> 1. Work: o ° <br /> o m <br /> 2. New Building Details No. Bathrooms .......... o iHt <br /> New Building .... Type of Coast r ctian: No.Bedrooms . ...... le A <br /> Addition [re! Cor- „ .,,,, . Septic Tank Size Gals. .......... <br /> .......... ......... ............ . ... ........... .. <br /> Sanitary .......... Size .... ..SL.. ft.x ...�...Z... ft ........ d <br /> U <br /> iA <br /> / <br /> Filling .......... - Height/.G......: Stories ......... 4a. Absorption Field Site: <br /> / <br /> Soil Type .................................... <br /> Moving .......... Area .......,I..�.�......................... (• o <br /> Grading .......... SI°Pe ......:............................. ..... » <br /> Mobile Home Perc. Rate .-................................ `- <br /> ....._... 3. Use (describe exactly, 1--family � ” <br /> Privy ..._..... home,garage,motel,etc.) Dry Well .......... <br /> Q. <br /> Well Seepage Trench .......... t i <br /> Subdivision .......... .. <br /> Privy .......... <br /> ......... ....... . _, <br /> Seepage Bed .......... ly <br /> Location of proposed structures and existingUf c <br /> structures,well,sewage systems,roads elate r, It p Ip rty is lo iced a A.highway <br /> a read h irn <br /> utback, shoe and back yard dimension and location and setback from all bodies of water. if property is located ata LEXIS inter t 9- <br /> section, show dm lealecti,PROPOSED <br /> ED STRe and t E setbacks DDITIO along dram and m the-Intersection CLEARLY LABEL EXISTING Q, <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS Dd o <br /> 5. Lot Size: _ Fi A. <br /> / g <br /> ..env ft. x .:g.1.2._ ft.- ...31000........... s4 ft - 1S <br /> ...... ....... v - <br /> Yl �s ad <br /> (.r/az <br /> N a.l <br /> o <br /> i <br /> v ao 4 D <br /> ive <br /> g <br /> frtYnyY oil <br /> 39 ' <br /> a rnr��tn <br /> at ? c <br /> m <br /> N�r- dei <br /> Ca_.0 <' �, <br /> 0 <br /> o <br /> ties <br /> N <br /> Signature of Owner or Agent Date - ° <br /> T X <br /> Remarks ........................................ <br /> ....f..........................:...........................................:. <br /> .........................._........._.........._... <br /> w : <br /> ....................................................................................................................... ................................................................... \ �„ <br /> ................................................................................................. <br /> .. .../.....�.................y........:. ... ................................... <br /> 9 <br /> ch <br /> Inspection Date ....................................... 4!(: (,If 1/�e✓..................._................. o 6 <br /> O W O <br /> Zoning Administrator o 0 o a 01 <br /> NOTE: A prch nt inary site inspection must be made and 'Ile upntovLl glen ted 'on all stnlctru es involving smli tory focili Grp � <br /> before construction can begin. In the case of sewerage dlepossd systems, a rally of the:percalation test must be attached to <br /> this applicationbefore a permit will be issued. Do not purchase or install a septic lank, 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 bund to exist. Changes in plans at specificotlans shall n6t be nt;ule without a- p"F.val of the Zoliing.Atlm in istrutor.' <br /> SEWER SV STEM SHALL NOT BE COVERED UNTIL INSPECTED By THIS OFFICE AND APPROVED. <br /> _ I <br />