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Burnett County Office of Zoning Administrator c o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3' o <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as < H :p <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m ° <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 ce V <br /> FJ.C.!V.....�Ik..C. <br /> O <br /> x.. . 0 <br /> 65 ..^......... .......... ............................................................................................ <br /> .... <br /> O ER (please print) CONTRACTOR or SURVEYOR or AGENT a [Q <br /> ...1. ......... r ' � I. P... s��.. ..w ' <br /> .... V. ..X....T`t.C.P...........................!!.c4..... ..;........................................................................ <br /> ADDRESS ADDRESS i^1� <br /> r <br /> .......... <br /> ADDRESS............................................................................ RS <br /> .ADDES .................................................................. � Q` <br /> ........................................................................................... .P.. —E................................................................................. Z. <br /> PHONE HO....NN <br /> :(t <br /> .......... <br /> PLUMBER............................................................................ .WL GELRILLE..R......................................................... 1 i01 <br /> ........................................................................................... ....D...DRESS..................................................................................... � ^ <br /> ADDRESS An o: n <br /> ........................................................................................... ....PHO........................................................................................ o' <br /> PHONE NE ' <br /> Z r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details <br /> New Building .......... Type of Construction: No. Bedrooms .......... '8 <br /> Septic Tank Size Gals. .......... <br /> Addition .......... .................................................... < <br /> Sanitary Size ft. x ft. <br /> .............. ..... ........ <br /> FillinglGrading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... AreaSoil Type .................................... i r i <br /> ........................... ............... <br /> Mobile Home ........ .......................................... � .. <br /> .. Slope o <br /> Perc. Rate ................................... <br /> Privy ,. 3. Use (describe exactly, 1 -family ' <br /> Well .......... home,garage, motel, etc.) Dry Well .......... <br /> Subdivision .......... Seepage Trench .......... 4� <br /> .................................................... <br /> Camping Unit Privy """"" ' <br /> Seepage Bed .......... C <br /> ------- -------------------- ------------------- ism Rt <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc.,should be sketched in Fig. A- Include road I <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway Inter- <br /> section, show the intersecting highways and the setbacks required along them and at the Intersection. CLEARLY LABEL EXISTING k <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> 5. Lot Size: Fig. A. 6. Location: 3 i <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... p <br /> m <br /> S6 0 <br /> 0 <br /> ° <br /> r <br /> Q z <br /> U' �.Q o <br /> d <br /> Fe Gi <br /> � m <br /> o '^. y m <br /> n <br /> Z 0 � nam 31 <br /> So , M <br /> :O 9 <br /> 7-/9- ........ �- C <br /> Signature of wne o Agent Date <br /> X <br /> Remarks ..................................................................................r................... ..... .... O <br /> �w� ..T......C° l/..1 ( .....[/u .l ..�s.. . 1 ..u:� l�:.:.t�.'... ....................... <br /> SII <br /> 5�..... .. �? .... 6P.... T ,��� ................ .....I....... -n <br /> 0: N + m + N m <br /> Inspection Date ....................................... ........ . .../.... . . ... ................................ R . m <br /> Nir v, rr o v, <br /> 7 7 Zoning Ad strator i 8 8 8 8 8 8 co <br /> NOTE: A preliminary site inspection ust be niade�and 'site approval granted on all structures Involving sanitary facihtles <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 riot 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 tie made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br /> �Je Ct�IC/1 �e,-n,;t 76Q—) <br />