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�i7^ <br /> Burnett County Office of Zoning Administrator P T 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as H ;(>\ <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use I OC <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 M iW <br /> o eCr <br /> _ O <br /> H f <br /> a <br /> .. . ...!�S.:S. ..../.. .......... ..�.. �... ..�'... .r............ ............................................................................................ m <br /> OWNER (ple a print) CONTRACTOR or SURVEYOR or AGENT n <br /> ! . ' I . . <br /> ... . J.. $ .r........."fl: .�................................. ............................................................................................ m -: <br /> ADDRESS ADDRESS � <br /> C <br /> ADDRESS•......... ADDRESS............................................................................. <br /> PHONEPH/O/. . .... ....... .................................................................. . .. •\ <br /> ....`.'..}.... �.�..'I..!... .. ............................................. <br /> .h . <br /> PLUMBER WELL DRILLER <br /> O <br /> ADDRESS ADDRESS m O <br /> ........................................................................................... . .................................................................................. 0 .: <br /> :nr0 <br /> PHONE P..HONE....... Z <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> 1. Work: 2. New Building Details No. Bathrooms .......... ra:V <br /> New Building Type of Cb ction: No. Bedrooms 3 `fl72 <br /> nq�w <br /> Addition / i�f Septic Tank Size Gals. e <br /> SanitarySize ... •....,. SO (� <br /> ..,�... r�.�.. ft. x ...rZ.�... ft. <br /> Filling/Grading ......•... Height............. Stories ............... � <br /> 4a. Absorption laid Site: M; i <br /> Moving ... Area ... Soil Type .................................... � 1410 r- <br /> Mobile Home .......... Slope .......................................... (* o <br /> a <br /> Privy ,,,,,,,,,, 3. Use (describe exact) 1 -famil Perc. Rate ................................... <br /> Well .........• home,garage, motel,etc. Dry Well ' i.0 <br /> Subdivision .......... Seepage Trench <br /> .......... <br /> .................................................... <br /> i <br /> Camping Unit ,,,,,,,,,, Privy ••y f�`u <br /> .................................................... Seepage Bed �.P..l!.i..7 <br /> ---------------------------------------------------------------------- <br /> Location of proposed structures and existing structures, well, sewage systems, roads etc.,should be sketched in Fig A. Include road <br /> o MOJ <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- ;� oma-, <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING o`o l['s <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. q o' o S <br /> --------------------------------------- - ---------------------- �i 47rr1 <br /> - <br /> 5. Lot Size: Fig. A. 6. Location: ilrn <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... :. <br /> it <br /> :y n <br /> o <br /> 0 <br /> � z <br /> :o <br /> 0 L <br /> 0 <br /> a <br /> a <br /> at, r- no : y 0 <br /> O y n <br /> 0 00 <br /> ►/}{� Qo <br /> ..1.... .. 6h.or... <br /> ....gent.................................... .......�..� .(J�....... Flo c_ <br /> Signature of Owner ADate <br /> X M <br /> Remarks ` «_ m m <br /> .............................................................................. 169 <br /> Y`,�' q� m <br /> . ......................... ....... ( : yl li <br /> .................................................................................................. <br /> .y ........... ... .. ................. t <br /> Inspection Date .KC.. ..... ....................... ... .. . .. .. . J <br /> L� .. .... :.Zoning minlstrator 8 8 8 8 8 8 on <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 marle without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />