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C",h C-t -I {' <br /> Burnett County Office of Zoning Administrator a o J0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT a 3. <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < - <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 <br /> �e.We.(.(.........w.n..�N.. .Y.............................. .................. .... .................... . . . <br /> ................................... <br /> OWNER (please Print) CONTRACTOR or SURVEYOR orAGENT N� <br /> a � <br /> ADDRESS <br /> ADDRESS <br /> cJ /. .•l ou/5.....Ph..Y.. I. K.e/...`?.t ;t.4 .......... ................................................................................. � <br /> ADDRESS ADDRESS <br /> ........................................................................................... ............................................................................................ <br /> PHpV -17M <br /> 7 PHONE ,� <br /> . . C . .+ri..4!�1....�../.'l.lJ... ..(.AI......................... . <br /> ^ .................................................................................... t <br /> PLUMBE —r , y t-a / WELL DRILLER <br /> tIL17...SM...74.....,S7.......$p°e.N{.Y...w=........... ............................................................................................ > •. o <br /> ADDRESS ADDRESS <br /> \ n o .r <br /> ........................................................................................... ............................................................................................ o <br /> PHONE PHONE Z N <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details ••• <br /> 0 <br /> New Building Type of Construction: No. Bedrooms ..... . p 0 <br /> Addition „ ,.,,,,,, �� Septic Tank Size Gals. .7.4:770 : O <br /> ..........................................y........ < <br /> Sanitary Size ft. x ..3.5..... ft. <br /> FillinglGrading „ ,,,, Height............. Stories ......(........ 4a. Absorption Field Site: i <br /> Moving Area Soil Type ................... i- <br /> .. ....... ........................................ .. <br /> Mobile Home Slope ................ '.... ..�............. 0 <br /> Privy ••.......• 3. Use describe exactly, -famil .' Perc. Rate .............. .................... <br /> Well ...'.— home, arage, motel, etc.) Dry Well .......... <br /> Subdivision Seepage Trench .......... <br /> ...........................I........................ Priv <br /> CampingUnit ,,........ Y ...•...... <br /> Seepage Bed ......... S ia <br /> --------------------------------------------------------------------- <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- p <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING i <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. O <br /> ___________________________________________ <br /> v <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ../..Y.A..... ft. x .�..�.J.. ft. . ............................... s4.ft. .............................................................................. �} <br /> C <br /> M <br /> IN c �. <br /> o .0 <br /> p . <br /> „ ttit <br /> 3 [w <br /> 0 <br /> 0 <br /> n `3F n m z <br /> m <br /> 6s, <br /> a �_ af <br /> Z C) a Da m <br /> O <br /> - _ <br /> -''`� 4J C <br /> ..., Sill!r�`' os�............. <br /> Signature ofvner r Agent / Date X <br /> Remarks . .... ... T ; O <br /> .(.'". ... ..... L.................... <br /> ...........w... .r .......(...................................................................... <br /> .................... ... .. .. .... <br /> ........... <br /> Inspection Date ..',1�...�'. ...JJ.�.--. ..... .. . . . . Z . . ..... ....... Q o ”' $ 4_ n <br /> Zoning ministrator d: $ <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures Involving sanitary aci Ides <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must he 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 be made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />