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Burnett County Office of Zoning Administrator �' o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3 <br /> a <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described end fz <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of he <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws nd 3 <br /> reg plations (the St (Wisconsin. 1 ^ a � <br /> �. . ....... oQ.?n'1 ............ � .. . ............................................. . .. a <br /> OWNER Ip pr-iYnt) CONTRACTOR or SURVEYOR or AGENT <br /> �CQ��LI.lX.7dC :YL!p.(.L.l�/Y......................................... .................................................................................. <br /> Y. -{/ ....Il..... E <br /> ADURESS ADDRESS <br /> ADDRESS .......... <br /> ADDR <br /> ESS........ ............................................. <br /> .............. ................................. ................................... .. . . . ............................................. <br /> PHONE ............ �I. ... i <br /> :\ <br /> W Z_ 00.5�`i <br /> PLUMBER........................................................................... WELL DRILLER <br /> O <br /> ................................................................................... L)�...... m i� <br /> ................................................ ............ ADDRESS <br /> .................. ............. . <br /> ADDRESS O < <br /> ........................................................................................... . ......................................... �...... <br /> PHONE PHONE .... • ... ..,� o O <br /> DESCRIPTION 4. SanitaryFacilities: <br /> 1. Work: 2. New Building Details No. Bathrooms L..... c <br /> No. Bedrooms <br /> ew Building ,..... Type,A9f Construct i n: "'I""" <br /> Add .......... .....C�Lf3 ..'.��..... J...... .. Septic Tank Size Gals. ... ...... <br /> . . ...... <br /> Sanitary Size . .�..... ft. x .. ft. "'�""" <br /> .......... ... ...... <br /> FIIlingl Orading Height ht............. Stories ............... 4a. Absorption Field Site: <br /> SoilType .................................... <br /> Moving .......... Area .......................................... f r i <br /> Moblla Home Slope ...................................L...... <br /> Perc. Rate ............................i....... <br /> Privy T, <br /> ,,,,,,,... 3. Use (describe -family <br /> Well home,garage, motel,etc.) Dry Well <br /> .......... — <br /> Seepage Trench o <br /> Subdivision � ° L}' <br /> 9 <br /> .......... .................................................... Privy <br /> Camping Unit .......... .................................................... <br /> Seepage Bed 1....... <br /> ----- ..1....... - _y <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fi9t A. <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is local d at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. I 0-- : <br /> ___________________________________________________________________-- — F <br /> 5. Lot Size: Loca n' <br /> ig. A. 6. <br /> 2f Ty Acfjf ��QQC('e C <br /> ................ ft. x .............. ft. — ............................... sq.ft. ......L....�........... //...........'.7. ,�-...............�L....... p `1� <br /> )J <br /> o <br /> / � a <br /> Lz / a <br /> z 'Z�- <br /> M <br /> d <br /> Mr <br /> X mvcnrD wm'y <br /> 0 c . c c Nn� '-- a y as <br /> �^ H N r0 b <br /> o Ham . Na <br /> Al m <br /> C <br /> M r, m <br /> . ..1.................................................................. O <br /> nature of Owner or Agent Date e <br /> / N <br /> Remarks ......................................................................................................................................................................... <br /> ......................................... ..... <br /> ........................................................................................................................................ �. No : o <br /> 9u' .. <br /> Inspection Date <br /> Zoning Admmi NN 6Nl tNo <br /> O O ar <br /> tr for 8 8 8 8 8 <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary fcilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this ap Ilcation 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 ben issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans od specifications 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 />