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.%:'--)(�'r <br /> Burnett County Office of Zoning Administrator V e <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 'Z 0 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the i <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. r: m <br /> ,. - <br /> OWNER iplease print) CONTRACTOR or SURVEYOR or AGENT <br /> / _ <br /> ADDRESS ADDRESS = I <br /> .. . :.K...........it!......... <br /> 5:.y. �:.. ................. <br /> ADDRESS ADDRESS <br /> �l.N.T.I... . �..-.. .......................................... ?..�...G....:.... :..b:.c............................ . <br /> ................ . <br /> PHONE . ............. .............................. PHONE <br /> �..... .. ...... .......... ............................................................................... ..... .o <br /> PLUMBE WELL DRILLER <br /> r <br /> ........................................................................................... . ...... . ............................................ ........................... ..... <br /> ADDRESS AD.. DRES.. ..S n c <br /> . . . ...........—..................................................................... .....ON....E............................................................................. ..... ;-: <br /> PHONE PHZ „ r <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details "" ""' i o i '• <br /> New Building Type of Construction: No. Bedrooms .... ..... <br /> ........ <br /> Addition .................................................... Septic Tank Size Gals. .... ..... <br /> Sanitary ...,,..... Size ... .a.... ft. x J)-ow., ft. .... ..... <br /> ........ <br /> 4a. Absorption Field Site:Filling/Grading .......... Height.../.0..... Storied.... Soil Type .............................. .....Moving f <br /> .......... Area ........ ........... r,; <br /> i <br /> Mobile Home .......... Slope .................................... ..... .. <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ............................. ..... i <br /> Well Dry Well m <br /> ..,,,,,,,, home,garage, motel, etc.) "" ""' — <br /> Seepage Trench o <br /> Subdivision — _ - "" -"" <br /> .......... r...Q.x. .a..� ......�.H.� � <br /> Camping Unit .......... Privy .... ..... <br /> .................................................... <br /> Seepage Bed -� <br /> Location of proposed structures and existing structures well sewage systems, roads, etc. should be sketched in Fig A. c` c <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is local at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersecti n. C--D' <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> --------------------------------- ---———————— i <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft— .......�0 sq.ft. ........................................................................ ...... <br /> 0 <br /> N <br /> p <br /> i o � <br /> C) — I <br /> z � <br /> Ong, IoI Q /C <br /> T' of 1 <br /> IC i Z <br /> VD <br /> IJ 57a RA PE o <br /> O <br /> 0 <br /> M Cf) MmrD .05{[(� N c . W N O c <br /> I�. CR n wo < D o n m <br /> ({ 0U5 NPammnm n ; <br /> ON ; f <br /> Z^moo <br /> » a ; y <br /> 2 m <br /> -- <br /> r <br /> aye. <br /> .Dw�r....�1.:..... .a ...................... .:7r au.,L.9.....1..9.. � fn <br /> Signature of Owner or Agent Date e <br /> Ol . <br /> T . <br /> m •• <br /> u. <br /> .................................................................................................................................................................................... . N : : : O <br /> .......................................................................................................... ....... .................. .. ..... .. ................................ ... <br /> T <br /> 8 O <br /> Inspection Date ...................... 1 e : R. <br /> N OJ N N <br /> - Zoning Adminis for <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary fac lilies before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this appli ation 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 AP OVED. <br />