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r r: <br /> AL <br /> Burnett County Office of Zoning Administrator Z' Z <br /> APPLICATION FOR SANITARY — LAND USE ---BUILDING PERMIT 3' 3 0 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as oo <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m c 'W <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 0. <br /> / 3 <br /> OWNER (please print) /5 .......... ....17.................... ��'.-.................................................... '^ m^ O <br /> „SY- /ice Ir M n CONTRACTOR or SURVEYOR or AGENT i <br /> JQ. <br /> -2as9....�gQfl:�.....��r.................rS.1.9A 7� Q <br /> ..... ADDRESS... .Q.........�5.��.: .. .................................... d <br /> ADDRESS ... ....... <br /> ADDRESS <br /> ............................................................................ ' <br /> PHAFK7....7.13.i................................................. <br /> ONE ............................................................................................ <br /> .. . ...... ............................................................................... PHONE <br /> PLUMBER . .......................................................................................... <br /> WELL DRILLER <br /> ADD <br /> ........................................................................................... . . ...... . ................................................... ........... ...... ........ <br /> . . . .� <br /> ADDRESS RESS <br /> PHONE . .................................................................. . o. <br /> PHONE ` <br /> DESCRIPTION Z r- <br /> 1 Sanitary Facilities: ° p^ o <br /> 1. Work: 2. New Building Details No. Bathrooms ,,, i <br /> New Building X g <br /> Type of Cgnstruction: No. Bedrooms : o <br /> f 'o <br /> Addition Septic Tank Size Gals. <br /> ............ .. .....r!^..a—..,.y .... <br /> Sanitary $ize ...�:d:.,... ft. x ..e?.,G...... ft. <br /> Filling/Grading Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Area ............ Soil Type .................................... <br /> o <br /> Mobile Home SIoPe ......................................:. . i <br /> . ......... <br /> .... .... <br /> Privy 3. Use (describe exactly, 1 •family Pere. Rate 7 <br /> Well home,garage,motel, etc.) Dry Well i <br /> Subdivision Seepage Trench '• <br /> Irak. G ................. .......... h <br /> Camping Unit "" <br /> Privy a '• <br /> __________ __________ Seepage Bed .......... i <br /> Location proposed structures and existing structures,well,sewage systems, roads etc.,should be sketched in Fig. A. Include road �! •� .� <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. CLEAR LV LABEL EXISTING o <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. n H• <br /> ----------------------------- C <br /> -------------------------------- o <br /> 5. Lot Size: Fig. A. 6.. Location: <br /> W t <br /> .Il.... ft. x . on... ft. — ............................... sq.ft. ............................................................................... <br /> Cen{cam 95 <br /> o <br /> ArPEa7f OQ,K :o f <br /> :-� <br /> e- <br /> QPPr�>r. 14- s- L d K � <br /> s <br /> :l\° 0 z <br /> DFa r n sCe <br /> �r c ° <br /> n Epvv <br /> u . m c <br /> Z o o n m <br /> V�... .> v1a` k��......... <br /> Signature of Owner or Agent • •• , D <br /> Dateo C <br /> Remarks .................................................................................................. ` X 70 <br /> ......... IM <br /> m O <br /> Aj <br /> iQf T <br /> : . <br /> Inspection Date ....................................... <br /> M <br /> I> o & ok m <br /> Zoning Administ for K� g g g g g g y ' <br /> TOTE:. A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> efore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> his application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> 19 until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> lith is found to exist. Changes in plans or specifications shall not tie made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />