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Burnett County Office of Zoning Administr for �' o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. 0 W <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and :LA <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the :Q <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the State of Isconsin. <br /> �AFr�/< ( s FcRT .................... ................................................................................. ...... <br /> OWNER 1plaese prints CONTRACTOR or SURVEYOR or AGENT <br /> Sl �S� `� �o/✓/ //7` 17..�.�...J..: 'ADDRESS.................................................................... ....... <br /> ..... R ........ .......... .............. .................. .. . tyl�/1 <br /> ADDRESS — <br /> voin/i✓w•rr�/ . /fir!...-�. y3/. . .. SU ' <br /> ......... .............. /:.. . �... .ADDRESS.................................................................... . <br /> ADDRESS <br /> ... .:-.! ..... .c ...................... ..... .............................................................................. ....... <br /> PHONE PHONE <br /> . .............................. ..... . ............ ....... <br /> ........................................................................................... WE LL DRILLER ........... ........... ............ <br /> PLUMBER <br /> . . . . . .......... ...................................................................... ....... <br /> ..... . . . ............................................................................... ADDRES..S <br /> ADDRESS <br /> o <br /> . .. ... ...... ......... . ................................................. - j <br /> . ................... ....... .................. .............. PHONE.............. ........ C C„'^. •�--(� <br /> PHONE <br /> DESCRIPTION 4. Sanitary Facilities: o <br /> No. Bathrooms •..•• <br /> 1. Work: 2. New Building Details 0 <br /> Type f Construction: No. Bedrooms . ••••.... i $ <br /> New Building .. ..... <br /> Adanson A 6 t. Septic Tank Size Gals. . ... <br /> Sanitary .......... Size ..��...�.PZ.... ft. x ...cT.�!.. ft. <br /> Filling/Grading .......... Height............. Stories ..../.......... 4a. Absorption Field Site: i <br /> Moving .......... Area ......................................... <br /> Soil Type ........................... ........ '• ?�, r i <br /> 0 <br /> Slope ................................. <br /> ...... <br /> Mobile Home .......... Perc. Rate .......................... ........ <br /> Privy 3. Use (describe -family <br /> i <br /> Well .......... home,garage, motel,etc.) Dry Well •• • Z <br /> Seepage Trench ......... o <br /> Subdivision .......... .......... .... .. . <br /> •�'` Privy ......... ' - <br /> Camping Unit ......... .........�.1"J.I�:f.7.C7.0 ................ <br /> ' Seepage Bed .•...... <br /> ------------------------------------------------- --- I E <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in F ig. A. <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property; loc ted at YXJ,, N <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the inters. tion. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. SLI <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. .................................................................... .......... <br /> orr � fill4C <br /> 3 <br /> / o a <br /> r <br /> t ( a S <br /> / Yo JU r P0 � <br /> ? lo V � T .Ni T ; C <br /> ^r Y— <br /> �� o <br /> �J <br /> i <br /> i ZI c M. W 0 0 m ao n <br /> -v M. > o c. ` m <br /> W ,n.e - co nny <br /> N . ;? N Q x) m Z$o : � � n , -4 <br /> P V o W a y <br /> HoRr <br /> » 0 : O <br /> rn <br /> Q . ...... . . 06 <br /> .......... .a- . .- .......... o <br /> Signature o caner or ent Date o . <br /> T: <br /> jertark .. ....... .................... ......... ........................................................ ........ /,CD - <br /> (( ...... �......... w u, <br /> uSt.... ..... 7.. .. ,^c>� c c .L .. ...... o : : o <br /> .........L74............. ... ............. <br /> .................. ......................................... . oo t <br /> ..........1.'......... ... . <br /> Inspection Date - 0 0 <br /> """""""""""""""' Zonin dministrator 8 8 8 0 8 rn <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitar facilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this a plication 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 teen issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND NPPROVED. <br />