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Burnett County Office of Zoning Administrator ce, M 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3, <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < N <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 a ifs <br /> a :4 O <br /> Wm J. Rank <br /> w f <br /> OWNER (please print) CONTRACTOR or SU RVEVOR or, AGENT <br /> 1704 East 58th St. a`�� `O <br /> ..................................................................................... ............... .. <br /> .......... d :o <br /> ADDRESS ADDRESS <br /> MInneapolis, MN 55417 <br /> ................................ <br /> ..... ..... ...................... ....... .. ........ ...............................................................................G�'1O <br /> ............... . .. . . : 4 <br /> ADDRESS ADD. R <br /> . ESS. <br /> 612-827-4255 .......... :� € x <br /> ......................... .............................................................................. .... <br /> PHONE PHONE a <br /> DonaldDaniels .......R'I'L' ......................................................................... \ �4 <br /> PLUMBER WELL DRILLER <br /> Siren, WI 54872 o <br /> ......... .............................................. ............................................................................................ u <br /> ADDRESS ADDRESS :s7 o <br /> ....... .............................................I........... \1 <br /> PHONE PHONE Z r <br /> DESCRIPTION 4. Sanitary Facilities: ° S ° <br /> .1 <br /> h <br /> Batrooms .....:. <br /> 1. Work: 2. New Building Details No. 5 <br /> T <br /> No. Bedrooms <br /> New Building .......... Type of Construction: •'�""" `� � <br /> Addition .•„•,•,•........................................... Septic Tank Size Gals. < <br /> ......... 7 0.0.0.... <br /> Sanitary ....X.... Size ft. x ft. """"" �T <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: � •:n <br /> N r <br /> Moving .......... Area Soil Type .................................... `G o <br /> Mobile Home . .... Slope .......................................... <br /> a ; <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ..........................2...... <br /> Well ,,..X.... home,garage, motel, etc.) Dry Well .......... :K <br /> Seepage Trench 'O <br /> ..........Subdivision .......... ,..........sin le...faidly...home <br /> Camping Unit Privy <br /> .......... ..••...... :N <br /> ........... ........................................ Seepage Bed t ;W <br /> — -------------------------------- -------------- w N <br /> Location of proposed structures and existing structures,well, sewage systems, roads, etc., should be, sketched in Fig. A. Include road w <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 Uq 'W <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. d .a o.�,> <br /> ---------------------------------------- --- <br /> 0 <br /> 5. Lot Size: Fig, A. 6. Location: <br /> o <br /> ................ ft. x .............. ft. . ............................... sq. ft. ............................................................................... 41 Ea w <br /> C , <br /> c(D — m <br /> N i O o. <br /> O K <br /> � V <br /> See attached w <br /> :m --I <br /> _ o <br /> yy E <br /> r'J .bi <br /> :r s <br /> �. <br /> ^ a .T o <br /> �V ° Z <br /> z o <br /> 09 <br /> q t <br /> : t � <br /> 5 <br /> in <br /> 7� artW Z <br /> '–' m c m <br /> m N d n < d ¢ m <br /> "O Q1 < C : •[ ro c <br /> m <br /> Z C) n 70 <br /> o O n ro <br /> EA – <br /> G< ?J m <br /> Oil' f� <br /> ......'...Y,....`........................................................ ...................................... o C <br /> Signature of Owner or Agent Date <br /> Remarks ...�!... .......0�a... .......:�............................................................................................................................... <br /> .............. . . :. . <br /> ............. (l."P�....JL6..i.. .SIC...T...................................... .. ............ ...,.,.................................................. ll <br /> Inspection Date .. .. .. .P ........ ... ..........:.:.`.4.`.'.... .... . . . . . N m <br /> ... . . ... ... . ........................ U O N N <br /> p Zon g Administrator :I 8 8 8 8 8 N <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 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 he made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />