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e5"_n <br /> Burnett County Office of Zoning Administi ator 0 10 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT µ. <br /> _ o <br /> TO THE ZON)NG ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and lac ted as < m <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Lad Use G <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinan sand the ws and regulations of the State of Wls onsln. B 0- <br /> JJ�� <br /> Nn <br /> � �$G............................................. ............. /. .. o <br /> ................................................................. �(p <br /> OW F}(pli print) CONTRACTOR or SURVEYOR or AGENT <br /> .. . ..5..3............................................ . ...... . . ..................................................................... ......... cL <br /> .. ... . <br /> ADDRE � ADDRESS <br /> ........................... .... . . . .................. .................................................................................. ......... <br /> DDRES ADDRESS <br /> Q J <br /> P <br /> ................... <br /> ......./............................................................ .P....N.E........... <br /> ..... <br /> ........ <br /> .............. <br /> ...... <br /> .............. <br /> ........... <br /> . ......... [ <br /> Hp '�A '� /� <br /> --e� k4& r C�Cll.'. �c't'C i7�F I <br /> ......... ...... . .- 1 .... ... . . .. ..................................... ......... <br /> PL ER WELL D HER +) <br /> . ...................... �� .. ................................. ....Ser. ' �....................................................... ......... <br /> o <br /> AD RFS _ ` y ?` ©� ADDRESS L� <br /> ....ON ............. .......... .......................................... ................................................... ............................. ......... <br /> PHONE PHONE H <br /> z n- <br /> DESCRIPTION 4. SanitaryFacilities: ' ° o ° <br /> 1, Work: No. Bathrooms v <br /> 2. New Building Details ��y���� o <br /> New Building .......... T of Construction: No. Bedrooms / .cT..... a <br /> Addition ,,,,....., �lE,v^-Z Septic Tank Si Gals <br /> .... ........ ..x ................. .. ,W/,� 7ru <br /> Sanitary Size .............. ft. x .............. ft. N�� <br /> Filling/Grading4a. Absorption Field Site: Ill <br /> �D � . <br /> .......... Height............. Stories ............... `,1 <br /> g .... Soil Type ....... I— <br /> Movie .......... Area ............... .. . . <br /> Mobile Home Sloe ........ ° <br /> Privy .•........ 3. Use (describe exact -fa IRate ............ ...... ..... . ....... <br /> Well ........ home,garage, motel, etc.) Dry Well .......... <br /> Subdivision .......... Seepage Trench ........_ W <br /> Camping Unit .......... .................................................... Privy .... _ <br /> ------------------------------------------------------------------- <br /> .. Seepage Bed <br /> Location of proposed strictures and existing structures well, sewage systems, roads etc.,should be sketched In Fig A. Incl. e road ] <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highwa inter a <br /> section, show the Intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXT TING <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> ---------------------------------------- � <br /> -------------------------- --- C ' ° <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. .................................................................... .......... <br /> N <br /> a <br /> � r <br /> O Or: <br /> 0 <br /> O <br /> / o � <br /> d <br /> m <br /> JJ to m to 'y <br /> c m w <br /> N d m <br /> o n <br /> z oo0 am <br /> O 0laa <br /> CD <br /> a m 3 <br /> ... 'w"'n'..... ................. ...................... ................................ ..... o p <br /> Signature of Owner or Agent Date — <br /> �X JJ <br /> Remarks ................................................................................................................................................................. ....... T In <br /> v <br /> � ' <br /> .......................................................................................................................................................................... ....... — <br /> II <br /> ' <br /> rNm <br /> Inspection Date ....................................... <br /> g, m <br /> ZoningAdminis` 'D $ $ $ $ $ y <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures I ivolving sanitary facilities <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolatioi test must be attached to <br /> this application before a permit will be issued. Do not purchase or install a septic tank, do any pl Irl or start any build <br /> Ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the in ormation conveyed here <br /> with is found to exist. Changes in plans or specifications shall not he made without approval of Ihe Zoning Adrninistratoi <br /> - <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />