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Burnett County Office of Zoning Administrator 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> C <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as '< <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m �Q <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. O. V <br /> ,.Ja!M.Z.S..a.. ........................ `.e.'L...:ST/ral'.'�t�C.............................................................. O <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT a <br /> re) Av <br /> .../.5. ...: .......... "'X.. `.................................................. <br /> ............................................................................................ <br /> ADDRESS ADDRESS <br /> CNS. .s l�n..........i ti<: . ........5:y2131............. ............................................................................................ <br /> ADDRESS ADDRESS i\ <br /> .............�y�>.T.: (............................................................ <br /> PHONE PHONE ^\ [ <br /> 1r�. ........ . ...r.......................................................... <br /> PLUMBER HL` DRILLER <br /> ............ ..:................................. ............................................................................................ <br /> ADDRESS ADDRESS m L1 <br /> n p <br /> ........................................................................................... ............................................................................................ O .i <br /> PHONE PHONE Z <br /> r <br /> DESCRIPTION 4. Sanitary Facilities: <br /> 1. Work: No. Bathrooms v <br /> 2. New Building Details <br /> New Building .......... Type of Construction: No. Bedrooms <br /> m <br /> Addition Septic Tank Size Gals. .......... <br /> .......... ....... ..... ...........-..... <br /> Sanitary .......... Size y ft. x ft. """"" <br /> Filling/Grading .......... Height............. Stories .......'........ 4a. Absorption Field Site: <br /> ...............................il <br /> Moving .......... Area ........................................... SoType ..... r <br /> O <br /> Mobile Home Slope .......................................... <br /> .......... , <br /> erc. Rate ................................... <br /> Privy ,.,� 3. Use (describe exactly, 1 -family P ' <br /> Well ....? home,garage, motel, etc.) Dry Well .......... <br /> subdivision <br /> Camping Unit .......... Seepage Trench .......... <br /> .......... .......�... .[ra r.�7.................... Priv """"" <br /> Y <br /> J <br /> ....................... ............................ <br /> Seepage a e Bed ......... —� :\ <br /> — .00 :\ <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched In Fig, A- Include road /— Z <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 m <br /> a <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> --_-------_----------------------------------------------------------- - _ <br /> I <br /> 5. Lot Size: Fig. A. 6. Location: _,4 <br /> ft. x .............. ft. — ............................... sq. ft. .................r....:.....?.`......................... ..................... <br /> 0 <br /> �J ) 0 o <br /> O 3 <br /> z. <br /> J <br /> U <br /> T <br /> m <br /> 1 Z <br /> o <br /> -16` <br /> jam/ J <br /> I, <br /> r L n m Z <br /> n CT <br /> No a o < m � `o a m <br /> Z 0 n <br /> o <br /> v1 _ J n <br /> 0 1 <br /> O : <br /> ..../....................C............................................... J?.......... ........... <br /> Signature of Ow er nt Date / <br /> Remarks ...... ..I.. ...r'.. ! y ` v Iv.4 7�....!'../. v`::........4�...�L. / � � x M <br /> ............................................................................................................. .... ..................... . <br /> Inspection Date .... ...... ...... ... . . ... . . . . H m <br /> ....................................... .. . g . ........................ /j . <br /> Zonin Ad Istrator <br /> NOTE: A preliminary site Inspection must be made and site approval granted on all structures involving sanitary facilities <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 not purchase or install a septic tank, do any plumhing or stall 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 be made without approval of the Zoniny Adm inistratol . <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />