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Burnett County Office of Zoning Administrator �' o <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 <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 , <br /> regulations of the State of Wisconsin. ;+ a <br /> .. ...:........L........,.. _ <br /> .:?..;...f.!.'.✓.a...�.i'�.�ie:?. �gN....ach A a f................................................ � 3 <br /> OWNER (please printCONTRACTOR or SURVEYOR or AGENT <br /> EAst 13,4sstK Rd Gi d�75 Cjax 3�' 0- ! a <br /> ADDRESS........................................................... .............. .ADDRESS............................................................................ <br /> ri <br /> .../L/v�r �...l c.u.Y 5h.: ..::..w�bsf:x..,..!:....5...... _ <br /> QHiv&i i:v.r..ois.........:5. fb3�................. <br /> ADDRESS ADDRESS <br /> 56 .- <br /> ......... <br /> ONE .....................................................................311? 3 <br /> i0o <br /> PHONE PH <br /> .................................................. <br /> .... ...................................................................................... . .WEL. ..L D.... ..RILLER.. ...... ................... :O <br /> PLUMBER f n <br /> ADDRESS ADDRESS n O <br /> .............. O <br /> ........................................................................................... . .......................................... ......................... »' <br /> PHONE PHON........E Z ,fin r <br /> DESCRIPTION 4. SanitaryFacilities: <br /> o <br /> i. Work: 2. New Building Details No. Bathrooms .......... 'o <br /> New a�ttdm No. Bedrooms ' <br /> Building ...�... Type of Construction: """"" i <br /> Addition ecd ,>r Septic Tank Size Gals. .......... <br /> .......... ..W ....... R.R/.r!5,..................... < <br /> Sanitary .......... Size .....u2.Y.... ft. x ....4y... ft. .......... <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: i ? '• <br /> Moving .......... AreaSoil Type .................................... c <br /> ........................................... Slope .......................................... <br /> Mobile Home ,,........ <br /> Privy .......... 3. Use (describe exactly,'1 -family Perc. Rate ................................... i <br /> Well .......... home garage,motel, etc.) Dry Well m <br /> Seepage Trench o <br /> Camps Privi <br /> -- <br /> Subdivision .......... ...... .flf.'fll..t''.......................... y <br /> .......... <br /> Camping unit .... ........ ......................................... Seepage Bed <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 g <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. 0 <br /> ------------------------------------------------------------ <br /> 5. <br /> __ __5. Lot Size: Fig. A. 6 Location <br /> 112.4... ft. x A/k') 12.. ft ....... ...... sq.ft. ..... ..... ...... ...................... <br /> ti <br /> r ? o <br /> 0 <br /> VL � 1 o <br /> D =. w DOo W 9 <br /> n �o < >n E E m <br /> � Hgmm3 <br /> rn0 Sri a2 : A <br /> 2 = : m <br /> -^.............. ....`......g:-. ..1.............. !' 0 <br /> Signature of Owner Agent Date $ <br /> Remarks <br /> w � <br /> ........................................................................................................................................................................................ <br /> " g <br /> ....................................................................................................... J� ....... <br /> Te ... <br /> sCI <br /> °J ioo mInspection Date ....................................... .. c <br /> or� <br /> Zoning mi o $ $ FgfA <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities 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 been issued. A permit may be <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 />