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Burnett County Office of Zoning Administr itor fC c <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. w <br /> TO THE ZONING'ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work describec and 'z 12 M S_ <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements o the m c <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> reg tions of the State of Wisconsin. _ <br /> a <br /> _ or <br /> ... ..... ................................ ...rRte.... VEYOR.orAG............................. ....... � <br /> OWNER IDI Drint) CONTRACTOR or SURVEYOR or AGENT i : <br /> .. i:2... .r................................. ...... .. . .: . ,..Jx...a:a.l........................ ....... d <br /> ADDRSS <br /> ......................................... .... ... ..�den.c.,... / .. �L3. ............... ....... y� <br /> ADDRESSA <br /> ^^ DDRESS \ <br /> ....K..fl ...C...}. .1./ �.�............................... ..... . . . <br /> PHONE PHONE flO Lny <br /> ... .1 �....:'�Y .. .................................... ................................................................................... ........ <br /> PLUMBER WELL DRILLER <br /> ........................................................................................... . .... ........................................................................ ........ <br /> ADDRESS ADD.... R..ESS » C <br /> •.......................................................................................... . .............................................................................. ........ O 11 <br /> PHONE PHONE.... Z N r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms ..... e <br /> New Building Type of Construction: No. Bedroo . ........ <br /> Addition Septic Tank ze Gal <br /> �> . ........ » <br /> .......... ........1.••K� . .. ..�....... <br /> Sanitary , ...-,--. Size ..a..f.�.. ft. x D.-iJ,T ... ft. ' """" <br /> Filling/Grading .......... Height............. Stories ..1............ 4a. Absorption Fie its: <br /> Moving .......... Area ...... ••tK�/ Soil Type ........ .. ............... ........ .r <br /> Mobile Home Slope .......... ....... ............ I....... » <br /> .......... <br /> Privy .......... 3. Use (describe exactly,-1 -family Perc. Rate ............... ......... ........ <br /> Well ........., home, arage,motel, etc.) Dry Well `• <br /> Subdivision Seepage Trench o . <br /> ........ .r'1. .. <br /> Camping Unit .......... � �„!.�.Y.. .................. Privy . ........ <br /> ................... Seepage Bed i <br /> ------------------------------------------------------------------- -- n <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. c <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. :•� i o <br /> —____ <br /> _____________________________________ --- <br /> 5. Lot Size: ft x Fig. A. 6. Location: V) S 1 /„ <br /> ................... ....................... ............... t <br /> . . <br /> lip <br /> N O <br /> O r r J <br /> f <br /> T <br /> Z <br /> 0 <br /> v <br /> J <br /> M <br /> M <br /> N c -om r n S. CD -0 <br /> n ,v < J J p -. S. m <br /> m Nn•< <br /> ow o o m <br /> ................. ...................................... <br /> A <br /> Signature of Owner or Agent Date g : <br /> Remarks m N <br /> H N <br /> ........................................................................................................ ..... .....................�. .. . ......�.... ...... N m <br /> /y <br /> Inspection Date ....................................... ..... . ......... a' F <br /> .. 1 f � N N p O ZoningAdminist8888 8NOTE: A preliminary site inspection must be made and site ap " val granted on all structuresinvolving sanitary f cilities before constructi <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this application 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 beE n issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans oi 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 AF PROVED. <br />