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&owew'- <br /> Burnett County Office of Zoning Administr itor 10 c <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT R. 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work describec and 0 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements o the n "� <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 ri <br /> regulations of the State of Wisconsin. _ n <br /> 4ddi7.e..fa.. .�I..C)4.h/]...cZ.S`e ................................ <br /> 4 .................................................................................... ....... A <br /> OWNER (plel print) CONTRACTOR or SURVEYOR or AGENT <br /> J.hi . 7.k.ipIVf.A.tt..Q../.V..orf..li.J.�1 .15 MIV. 6 /./............................................................................ ....... a � <br /> ADDRESS ADDRESS <br /> Bucnetl •�ywlh,.. 1 ....... ....... <br /> F � <br /> ADDRESS ADDRESS r �dRllnc <br /> 3 <br /> Burnett Co. G <br /> .s3.`NE ................................................................. ort. Cer.......... ....... � (�(%� io <br /> PHONE PHONE 'R�Ytif Tr BOX 3,00-102 `(' - <br /> .............................................................................. ............ <br /> Sirl!NAL507.g.................. ....... <br /> PLUMBER WELL DRILLER ' <br /> ...................................................................... .. <br /> . .................. <br /> ADDRESS . ...... .. ...................................................................... ....... ql <br /> ADDRES.. ..S i o <br /> ............. . . . . .................................................................. . . ........................................................................... ....... C <br /> PHONE PHON......E N <br /> DESCRIPTION 4. Sanitary Facilities: o o `(d <br /> .. .... ` v <br /> t. Work: 2. New Building Details No. Bathrooms 0 •� <br /> New Building .,,, T e of struct,iQ�,n�Q:, No. Bedrooms .. �..., i� R <br /> Addition •J •••, „�• V�/:1./•......... Septic Tank Size Gals. .. ....... I <br /> Sanitary Size ..y.......... ft. x ...:%�.... ft. .. ....... <br /> Filling/Grading .......... Height........... Stories ............... 4a. Absorption Field Site: <br /> Moving Soil Type .................. <br /> .......... ........................................... .......... ....... i or <br /> Mobile,Home Slope i <br /> O <br /> .......... <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ........................... ....... d q, <br /> Well home,garage,motel, etC.) Y n ' <br /> .......... Dr Well .. ....... y <br /> Subdivision .......... Seepage Trench z <br /> I'f am.i. .�t 1_�4 44�f1.0t1. Q � <br /> Camping Unit ,,,,,,,,,, `, ,,�I Privy .. ....... ,�L7 �tJ1 <br /> ........................8.(. .................. Seepage Bed <br /> Location of proposed structures and existing structures well sewage systems, roads, etc. should be sketched in Fi I. A .W 'T <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is local d at � iA <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersec ion. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> ----------------------- -------- --- -- J <br /> 5. Lot Si e: Fig. A. 6. Location: L _ <br /> y�. .. ft. x .............. ft. — ............................... sq. ft. Y.0o� <br /> RIq W j-O w,n ,+- <br /> C <br /> o � <br /> 0 .I ` <br /> gi <br /> T <br /> Or `� <br /> i' <br /> (n rr > co M <br /> / / m Nam 1,OM <br /> m n S <br /> y C y S <br /> u, z <br /> c — <br /> ..................................... <br /> Ow <br /> S' ature of Owner or A ent _ Date <br /> emarks .&7. .✓t�.. .- 5 lam-, Cto a <br /> T ' <br /> N m N $ <br /> a _nInspection Date ....................................... ...... Im11 <br /> Zoning Administrato ..7!'1'1 $ $ $ g rn <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary fac lities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this applic 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 ors 3ecitications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />