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LIZ , CG)7�1�1 <br /> Burnett County Office of Zoning Administrator Ir c <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ; 3• <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and # <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 � <br /> regulations of the State of Wisconsin. a <br /> . W*NER please �...Fc.zSum.................................... ............................................................................................ <br /> OWNER�eue print) CONTRACTOR or SURVEYOR or AGENT <br /> /rlir.nehaha Aue. <br /> a,. - <br /> a <br /> ADDRESS ADDRESS is <br /> /..?1.117nea�/(,s,../77A/ S V66. �. ............. <br /> ............................................................................................ <br /> ADDRRESS/' ADDRESS <br /> PHptJE /��...a� ..� l..T.../...................................... .PHONE <br /> 1Qa'e... um................................ <br /> i <br /> PLUMBER WELL DRILLER <br /> X..........s:....l.cleLufe.....k/ ........... 3.... 0 <br /> AD RESS ADDRESS <br /> ... ........................................... ................................................ .. ....................................... o <br /> lis Ply P �. <br /> PHONE PHONE <br /> DESCRIPTION 4. SanitarYFacilities: ° 0 0 <br /> 1. Work: No. Bathrooms •••• <br /> 2. New Building Details •• '•' _ c <br /> New Building ,,...... Type of Construction: No. Bedrooms <br /> Addition ✓ Septic Tank Size Gals. <br /> .......... ?� <br /> Sanitary .......... Size .............. ft. x .............. ft. . <br /> Filling/Grading ....,..,.. Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Area Soil Type .................................... ' i » <br /> Mobile Home $IOPe .................. ................... <br /> .......... <br /> Privy .......... 3. Use (describe exactly,'1 -family Perc. Rate .............. .................... <br /> Well .......... home,garage, motel, etc.) Dry Well .......... N <br /> Subdivision .,,,,.,,,, �U �j Seepage Trench .......... o <br /> ....�... .�-'A ........�i..rX��.... Privy <br /> Camping Unit ...I...... ....... ....... .......... <br /> ....................... .... Seepage Bed <br /> __ -------------------------------------✓ -f 'y <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. .U a <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. :!�, o <br /> _____________________________________________________________________ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... <br /> N 'J O <br /> 0 V O <br /> 13a�(DI, o <br /> oj?4j)11af, <br /> o <br /> I(15fd 1�P� M <br /> Z <br /> 0 <br /> D <br /> a <br /> m <br /> 37 W -pWr- Dmm -0 <br /> SD, Nnc - nm nay <br /> aa< dc0 > > <br /> O � O <br /> 0 l O D <br /> a : <br /> 2 m m <br /> n o � <br /> � C <br /> o : 9 <br /> ........................................................................ ...................................... <br /> A : m <br /> Signature of Owner or Agent Date g O <br /> m ' m <br /> Remarks ......................................................................................................................................................................... <br /> V11. - w <br /> 5> <br /> 8 : $ <br /> �,` „ <br /> Inspection Date .............. N ro <br /> ......................... a ut o m <br /> . ..� �'� �....................... m <br /> onln Ad nistrator 8 8 8 8 V! <br /> NOTE: A preliminary site inspection must be made and site a proval granted on all structures involving sanitary facilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this application 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 or 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 />