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..Giint� 0-71 <br /> Burnett County Office of Zoning Administrator a0 0 <br /> APPLICATION FOR SANITARY -T LAND USE — BUILDING PERMIT ; 3 <br /> 0 <br /> TO THE ZONING ADMINISTRATOR. The undersigned herebylmakes application for a Permit for the work described and located as <br /> ce . <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requ'Irements of the Burnett County Land Use <br /> Ordinance, Sanitation Code, and with all other applicable Coon y Ordinances and the laws and regulations of the State of Wisconsin. a :V <br /> ............................................................................................ <br /> OW4R (please print) I CONTRACTOR or SURVEYOR or AGENT a <br /> r..... �A <br /> ADDRESS ADDRESS <br /> ..We{ ,bZcnw S'f�93 <br /> ADDRESS ADDRESS <br /> ......................................................................................... . ............................................................................................ :\ <br /> PHONE � ' ^5 IO PHONE <br /> b/ trL ............................................................................................ <br /> PLUMZjR (n� /^ WELL DRILLER <br /> 119 <br /> ................. ................................................ . ............................................................................................ _. <br /> ADDRESS ADDRESS ' <br /> � O <br /> c <br /> PHONE PHONE o Z H <br /> DESCRIPTION 4. Sanitary Facilities: is ° 0 0 <br /> 1. Work: 2. New Buildin Details No. Bathrooms .......... .t, 0 <br /> New Building No. Bedrooms F ° <br /> ......... Type of Co truction: -r? _' <br /> m <br /> Addition ................/.._. ................................ Septic Tank Size Gals. .......... p i <br /> Sanitary .......... Size ....,I.W.. ft. x ...:.70.. ft. <br /> .......... <br /> Filling/Grading 4a. Absorption Field Site: <br /> .......... Height........ . Stories ............... <br /> MovingSoil Type ..................... ........ <br /> ......... Area .......... ................................ <br /> )J:i. <br /> Mobile Home .......... Slope .......................................... O <br /> .. <br /> Privy ...... 3. Use (describ exactly, 1 -family Fare. Rate ................................... <br /> Well home,garag , motel, etc.) Dry Well .......... !a <br /> 'A <br /> Subdivision ."rG Seepage Trench .......... t :\ <br /> Camping Unit ,,.,,,., Privy .......... 7\ <br /> Seepage Bed .......... S•' <br /> ell C <br /> Location of proposed structures and existing structures, well, s wage systems, roads,etc.,shoud be, sketched in Fig_ A_ Include road 1, p Q <br /> setback, side and back yard dimension and location and setba k from all bodies of water_ If property I, located at a highway inter- O a <br /> section, show the intersecting highways and the setbacks requir d along them and at the Intersection. CLEARLY LABEL EXISTING <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDIT ONSa <br /> . o' <br /> _________________----____--_---____._ ----____________—_-- -_____.._..___._______ <br /> 5. Lot Size: ig. A. 6. Location: C' <br /> ................ ft. x .............. ft. . ............................... q. ft. ............................................................................... <br /> n` <br /> N <br /> /) m <br /> N 0 O <br /> O YI <br /> 0 O <br /> J`l` � <br /> V <br /> a <br /> yyr� <br /> � O <br /> Z <br /> O <br /> m <br /> ar <br /> m <br /> 0 5 <br /> o � ya <br /> 0 <br /> O n <br /> /J fA —_ <br /> Signature of Owner or Agent Date — <br /> X <br /> Remarks ......................................................................................................................................................................... 7 . . . . . . m <br /> m <br /> ........................................................................................................................................................................................ — <br /> u <br /> ...................................................................................................... .... .................rte. i <br /> ..... . ....... <br /> ... .... .. � mInspection Date ....................................... . . . . . ....... ... ... <br /> . v . ........... <br /> m <br /> Zoning Administrator K j S S S S S 8 rn <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structuresinvolving sanitary facilities <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test be St be attached to <br /> this application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing r start any build- <br /> ing until a permit has been Issued. A permit may be revoked if misrepresentation of any of the informaI n conveyed here- <br /> with is found to exist. Changes in plans or specifications shall not be made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND PPROV ED. <br />