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Burnett County Office of Zoning Administratord o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < ._. <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 0- <br /> 7/.mkp. F�sc.G .t ....... ............................................................................................ y o <br /> ........ <br /> .................... _ <br /> m • <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT n <br /> 5�... . .... .k.....n5.ssrt�.K..... ................................... ............................................................................................ <br /> ADD ....RESS ADDRESS <br /> ............................................................................ <br /> A'p,S RESS ADDRESS ' Q <br /> O <br /> ........5�./..-....1a.3. ..3............................ ............................................................................................ <br /> W X <br /> PHONE / ' / PHONE <br /> �.2......... KQ.._ f l S.......... .. . �...p.. fir........................... <br /> PLUMBER � � p WELL DRILLER <br /> (.t12. 5is <br /> � ..............w.(...5......................... o <br /> _. <br /> ADDRESS ADDRESS <br /> ........... .ro ... ....................................................... ............................................................................................ \ �� <br /> PHONE PHONE z h ^ <br /> DESCRIPTION r— "�• <br /> 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms V_ o <br /> New BuildingT No. Bedrooms o,, a <br /> 1 <br /> .......... ype of/CConstructt)-on: �t m <br /> Addition ... . . ...C:�iL..S.I..'.�`. ...... Septic Tank Size Gals. ........ <br /> Sanitary � Size .............. ft, x ..... .... ft. .......... <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: 'W E <br /> Moving .......... Area . . .................... Soil Type .................................... o <br /> Mobile Home . . .. ........ .. . . Slope ............... ....... ......... ........ .. <br /> .......... .�.. �... <br /> Privy .......... 3. Use (describe exact) 1 -family Pairs. Rate ....... ........ �? <br /> Well .......... ome- garage, motel, etc.) Dry Well .......... <br /> Subdivision ,,,....,,. Seepage Trench .......... i E� <br /> .................................................... �`.� <br /> Camping Unit .......... Privy <br /> ............................ ................ ...... <br /> Seepage Bed . .... --a <br /> Location of proposed structures and existing structures well sewage systems, roads etc.,should be, sketched in Fig. A. Include road T4 <br /> setback, side and back yard dimension and location and sethack from all bodies of water_ If properly is located at a highway inter- o- <br /> section, show the intersecting highways and the setbacks required along them and at the 'mmrsenion. CLEARLY LABEL EXISTING �- <br /> STHUCTUHES AND PROPOSED STRUCTURES AND ADDITIONS. ,. ��f/ pKZ' <br /> 5. Lo Size Fig. A. 6. Location: <br /> .... ). ft. x ..� ... t. — ............................... sp. ft. ............................................................................... <br /> 111 p <br /> Q1 <br /> N3O <br /> 3 <br /> as ' '1 <br /> YI qA ' <br /> o <br /> b <br /> <I � <br /> N1 77 <br /> N <br /> N <br /> \�S <br /> �J N rL .N to Z <br /> c: d <br /> ff3 n f <br /> N d W <br /> Z o o 0 a a m <br /> o _o n <br /> 14 <br /> /� �l/ � 2C <br /> ee <br /> o <br /> - O3 <br /> te � �^ S o J m <br /> U <br /> ..... ................. ................................................... ...................................... v o <br /> Signature of Owner or Agent Date <br /> Remarks . . —C`-G..� x <br /> T C <br /> ........... .j :G.< .... �G ...... w: .l` ...:..................... ....................................................................... <br /> N .0 <br /> ................................................. ..................................................... .............. ...... ... ..................... <br /> //^ .. .... : I <br /> Inspection Date .L..�/.�,L....-..1�: ....... --�Gf� (J Z. <br /> ? g u tin o o ria m <br /> . .. ..............1........: ..... .... ...................... i <br /> Zoning Ad nistratorKJ 8 0 0 8 8 8 ti <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 made without approval of the Zoning Adm inistrztol . <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />