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Burnett CountyOffice of Zoning Administrator d o i 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT r4 3 <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Perrnit for the work defended and located os <br /> shown heroin. The undersigned agrees that all work shall bo bene In occoNonca win tlra re rno rnenls of IM1e Burnett County Land Use o o `=t <br /> Ordinance, Samenoo Code,and with all other applicable County Ordinances and IM1e laws and regulations of the Slate of Wisconsin. 3 i� ( <br /> E <br /> a <br /> 22 I?yri J — <br /> f <br /> c .v.v........... .......... {........._s..._�.�� ........................ ...................... ..%....................................................... f' o <br /> OWNER (please print. CONTRACTOR or SURVEYOR or AGENT <br /> ..............._._...._ a . <br /> a <br /> v <br /> ADDRESS ADDRESS <br /> 5.. ... n�. ......h1.�V_...�.,5.19_�............ ......... <br /> ADDRESS ADDRESS <br /> ....f9 q9.6'�3.` Q................. .................. . .................................. .......... ...... ........ <br /> PHONE <br /> Ai <br /> PHONE Aial <br /> .. . . . ................................................................................. ............................................................................................ `I :� at <br /> PLUMBER WELL DRILLER ; <br /> .. . . . .................................................................................. . .. . . . . ............................................................................ <br /> ADDRESS ADDRESS W 0 <br /> W ° 7 <br /> ......................._._...._..._.._...._._..._.................................. ..... ............._............................................_..............._........ o <br /> PHONE PHONE. Z r, <br /> DESCRIPTION 4. Sanitary Facilities: o o f,, <br /> 0 <br /> 1. Work: No. Bathrooms v ' <br /> ,/ 2. New Building Details ---- ' <br /> New Building ...0 Tyne¢f Constructiv on: No. Bedrooms ..rte.. i� <br /> Addition ..._._1.�.�:4.C!Y�.75_........ .......... Septic Tank Size Gals. ... [ <br /> Sanitary .„..._..,_,,_.,_...__. ...�. ..... ft. x ._. .... ft. w. <br /> Filling Height_...... .... Stories ........... ... 4a. Absorption Field Site: Z,\A <br /> Moving Area ... <br /> rea <br /> ir <br /> .......... Soil Type .................................... <br /> ...................... . .. <br /> Grading '6 <br /> .......... Slope ........................_......._.......� i5 <br /> a <br /> Pere. Rate ..... ............. .:....... ..... P <br /> Mobile Home ......._. 3. Use (describe exact. 1 family P, <br /> �� —1 <br /> Privy home,garage,motel, e[c.) Dry Well ........_ r-1; T• <br /> Well ..�._. Seepage Trench .......... .a' <br /> Subdivision Privy <br /> C.... ......u(.).. <br /> ....._...................... Seepage Bed ( QA..V/ (U iN <br /> ---------------------------------------------------------------------- <br /> as <br /> Location of prod r s"id ras and n and <br /> structures well setback <br /> garage m all bodies <br /> o an,at rM1oulJ M Profanity <br /> is to in Gig a highway <br /> ,pad •` t �� o- <br /> f <br /> setback, fide end back yard dh,hvion and this <br /> ant. setbpck from all m and at thetint if ction.tC islocatedat o LEXIS Inter- <br /> section, show the interseOPO ED STRUCTURES <br /> RE setbacks ADDITIONS d along them and at the intersection.CLEARLY LABEL EXISTING <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. — W o <br /> o i <br /> (n <br /> 5. Lot Size: Fi, A. 6. Location: :[ an <br /> Ej <br /> dZ <br /> n <br /> T <br /> �w• T <br /> T o <br /> 1 a <br /> Ji" b rn <br /> Up k <br /> ' IbFa9 'F <br /> 31 der— PSI <br /> WW <br /> de �C� <br /> z o <br /> LU U t'Jr ///1 ��/a.-5 A <br /> IkK gna[urc of Owner or Agent UUU Dale — <br /> x <br /> T <br /> Remarks ......................................................................................................................................................................... m.� ; � <br /> w ' <br /> ..................................................................----........................... <br /> .., . . ................................ rn <br /> do <br /> . »m—NT <br /> 4i .. 0000 of In <br /> 'luspection Date ...._........................._...... 12F.........._..._. Bud �y.�..' J ................ i 0000om <br /> Zoning Admi6istrator"J :\ Ci 0 0 0 0 o y <br /> NOTE: A prelllnlnary site insuectlon must be made and He approval granted o all structures li .11.119 sanitary facilities <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the Vercolat...n test most be attached to <br /> this application before a natant will be issuer. Do not purchase or install a septic lank, do any plumbing or start any build- <br /> ing until a Permit has been issued. A pmmil rt ay be r yoked if mi... e,entation of an, of the In form otion conveyed hent- <br /> Aith i5 found to exist. Changes to plans or specifications shall .nt be made without an Pr oval of the Zoning Ad n+Inulraird <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPE:CI'ED BY THIS OFFICE AND APPROVED. <br />