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Burnett County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT m 3• <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the 4 i DO <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> regul tions of the State of Wisconsin. <br /> ..I�t��?. %�n....Jel.,�ia� .......................................... ...... .e1 ............................................................... ...... <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT <br /> z=.5:..�Qm6�iCJ' ,.,�!........................... ..... . . . . . _ <br /> ADDRESS ADDRESS <br /> . . . ............................................................................ <br /> A {.kkS. L.(J.�lyr...f.... .....GCciI.L.X .................... .ADDRESSQRESS <br /> r'� •"�"� <br /> ........................................... <br /> ..................................... ............................................................................................ <br /> PHONE <br /> fPHONE <br /> . ......................................... <br /> PLUMBER WELL DRILLER ; <br /> s ,Y..d.�?5...k� ..�( .... ���3..... .................................................................................... ....... <br /> A09V RESS ADDRESS 0 <br /> 'S (G...-. ZZRP. ............................................ o o n <br /> 0. t <br /> PHONE PHONE Z N r <br /> DESCRIPTION 4. Sanitary Facilities: 00 <br /> ° <br /> 1. Work: 2. New Building Details No. Bathrooms c <br /> Now 6ullaing ...,,,,,.. Type of Construction: No. Bedrooms .. ....... <br /> O <br /> Addition ✓ .................................................... Septic Tank Size Gals. .. ....... :� <br /> .......... <br /> Sanitary ..r ... Size .............. ft. x .............. ft. .. ....... <br /> Filling/Grading .......... Height............. Stories .............. 4 . piField Site: <br /> Moving .......... Area ........................................... Soil Type ............................ ....... �x� <br /> o <br /> Mobile Home $IOPe .................................. ....... � •. <br /> Privy 3. Use (describe -family <br /> Parc. Rate ........................... ....... i <br /> _ Well <br /> - :.. home,garage,motel, etc.) Dry We .. """' <br /> Subdivision .......... Seepage Trench o ' <br /> Camping Unit .......... .................................................... Privy .... <br /> Seepage Bed ... <br /> ________________________________ _______ __________________________ . <br /> _ _ <br /> Location of proposed structures and existing structures well sewage systems, roads, etc. should be sketched in Fig. A. ;+V •g <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at L <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersec ion. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> ___________________________________________________________________ <br /> 5. Lot Size: Fig. A. 6. Location: :V E <br /> ................ ft. x .............. ft. . ............................... sq.ft. ...................................................................... ........ <br /> N O <br /> n <br /> c �J <br /> O <br /> O <br /> a <br /> r <br /> Z z <br /> D <br /> a <br /> e <br /> m <br /> Y� <br /> M mvrnr Ddoco -0 <br /> m Nam — o. m nam <br /> c <br /> o ino D� <br /> o c 0 m <br /> O <br /> = c <br /> o a <br /> x n : m <br /> .. ........................................................................ ...................................... a O <br /> Signature of Owner or Agent Date <br /> o , <br /> Remarks m o <br /> m <br /> ?vl <br /> 3�. '' (�-.. . .... <br /> Inspection Date " NCON � � Nm <br /> ....................................... '�... .........�U.... .. tit N N O O Ut m <br /> Zoning Administratr71 8 8 8 8 S 8 w <br /> NOTE: A preliminary site inspection must be made and site appanted on all structures involving sanitary fa ilitias before construction <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 issued. A permit maybe <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 APPROVED. <br />