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att County Office of Zoning Administrator 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3 <br /> 0 <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as m .r <br /> u VJ <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 <br /> f O <br /> v O <br /> h N <br /> 19r t C S <br /> � 1 1'X /`� <br /> Of ..,�..... ..................... ........................................................................ . � � > <br /> OWNER (ple se print) � CONTRACTOR or SURVEYOR or AGENT o. � <br /> 7�-- <br /> ..�.l.:.Y:. .......... <3- y`...... .... ..... .rurr..!?...4. .LF.......... :;:'.L................................ a <br /> ADDRESS ADDRESS <br /> ........................................................................................... . ...... . . ............................................................................... <br /> ADDRESS ADDRESS <br /> ....................................I......4..................... . . . . .................................................................................... <br /> PHONE <br /> PLUMBER <br /> D / J <br /> PH�VE i <br /> WELL DRILLER <br /> ........................................................................................... ............................................................................................ �� 0 <br /> ADDRESS ADDRESS 1 <br /> ............. <br /> PHONE PHONE <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> 1. Work: No. Bathrooms � <br /> 2. New Building Details :� o <br /> New Building yyNo. Bedrooms <br /> ...RY. Type of Construction: <br /> Addition r q rM Septic Tank Size Gals. ... <br /> Sanitary ... .. Size ... ft. x ... <br /> � <br /> �" ... ft. / (-l' V <br /> . . . v.:.�... ..... <br /> .. ...... <br /> FillingtGrading ,,,,, ,,,, Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Area ............... . . Soil Type .................................... o <br /> Mobile Home .......... �!<'�< ,� .! (`.. . . rlrQ Slope ...................4...................... <br /> Priv Perc. Rate ................................... . <br /> Privy V 3. Use (describe exactly 1 famil F <br /> Well lN..,,., home,garage, motel, etc. Dry Well .......... <br /> subdivisionSeepage Trench .......... A <br /> Camping Unit .......... .................................................... Privy <br /> .................................................... <br /> Seepage Bed------ <br /> ---------------------------------------------------------- a <br /> 0 <br /> Location of proposed structures and existing structures, well, sewage systems, roads, eta, should be sketched In Fig. A. Include road <br /> v <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway Inter- W _a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING W <br /> W e <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. 4 0 <br /> ---------------------------------------------------------------------- <br /> :GI <br /> 5. <br /> ---------------------------- <br /> 5. Lot Size: c r c S Fig. A. 6. Location: h :e <br /> ..�.�.�(....... ft. x .............. ft. - ............................... sq.ft. ............................................................................... a <br /> V <br /> P p\' <br /> tla N <br /> N <br /> n <br /> N o <br /> D <br /> _3 <br /> O LV <br /> 0 <br /> \ Z9 <br /> Z9 <br /> V Q <br /> m C1 <br /> Z <br /> ��n o <br /> f <br /> M 01 r a m z <br /> .o tNn <' <br /> m <br /> Z o0 <br /> o aaro <br /> vs — <br /> 0 <br /> a <br /> ................... ...................................................... ...................................... o C <br /> Signature of caner or Agent Date <br /> S' ler�...l� �,... rt..7y.-�. X m <br /> Remarks .,4C/.... m m <br /> m <br /> ........................................................................................................................................................................................ <br /> ca <br /> `n 11 <br /> M : <br /> i Nm <br /> .. ...... ...... <br /> Inspection Date ....................................... d o o u m <br /> Zoning Admi Istrator 'Cl) d Ir` 8 $ 0 0 0 8 rn <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary tacllltles <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 Adm Inistratol . <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />