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Burnett County Office of Zoning Administrator 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < N -^ •W <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use e <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws andel regulations of the State of Wisconsin. <br /> .. r 1. rel/ N M <br /> ... ... ............................................................ . . . ...... ... .. a <br /> .... ...... . . . <br /> OWNER (pleas r C RA SU RVEVOR r AGENT oa <br /> 9�� — : <br /> .................,.......rlf/.......S...Y.. ..3......................... d <br /> ADDRESS ADDRESS <br /> .. . . . ................................................................................. <br /> ... .!a 9s........................................................... <br /> ADDRESS ADDRESS :U <br /> PHONE................................................................................ E <br /> HON <br /> .P ....... <br /> .......... <br /> .................. <br /> .... <br /> ..... <br /> ................... <br /> .... <br /> .............. <br /> \ <br /> ........................................................................................... . .....L D.....RI....LLE.. R.. ....................................................................... <br /> PLUMBER WEL.. <br /> O <br /> ADDRESS ADDRESS n 0 <br /> n O <br /> PHONE PHONE Zr• <br /> DESCRIPTION 4. Sanitary Facilities: o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details •••••••••• o <br /> New Building .......... Type of Construction: No. Bedrooms .......... <br /> Addition Septic Tank Size Gals. ..... F <br /> < <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... m: <br /> Absorption Field Site:Absor A ` ' <br /> Filling/Grading Height............. Stories .............., 4a. p <br /> Moving ....... AreaSoil Type ............................I....... <br /> Mobile HomeSlope o <br /> ........................................... .......................................... <br /> .......... <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Well home,garage, motel, etc.) Dry Well .......... _k i <br /> SubdivisionSeepage Trench .......... d i <br /> ......................................I............. <br /> Camping Unit .......... Privy .......... <br /> ...................................I................ Seepage Bed <br /> .......... <br /> ---------------------------------------------------------------------- <br /> Location of proposed structures and existing structures well, sewage systems, roads, etc., should be sketched in Fig. A. Include roadpN' Q <br /> 0 <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter-0e u a <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. p' <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... <br /> 01 <br /> _5�U <br /> s <br /> N O <br /> 0 <br /> F ?� 0 <br /> �T O <br /> )v Z <br /> 0 <br /> a <br /> m <br /> rn v 0 W Z <br /> C C N <br /> LD. <br /> n = y n m <br /> - m <br /> 0 a � 70 <br /> m <br /> Signature of Owner or Agent Date <br /> X <br /> Remarks .......................................................4.............................. T mm <br /> m : <br /> ............................................................................................................ .. ............. <br /> II <br /> g€q Nj . m <br /> Inspection Date ....................................... ...... <br /> m <br /> . .. ....... . ....... .... .................................... H <br /> Zoning ministrator 0 8 8 8 8 8 8 N <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> this application before a permit will be issued. Do not purchase or install a septic tank, 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 found to exist. Changes in plans or specifications shall not be made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />