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` .—fl7? Iaf»7 <br /> Burnett County Office of Zoning Administrator o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ; 3. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < N -^ <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m �I <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. <br /> ............ <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT a <br /> 1... .. ..3........... ....................................................... ..... . — <br /> ..................................................................................... d <br /> ADDRESS. d ADDRESS •* <br /> lU ..! ............i..../���.......�...s:...s. .......................................................................................... �V ' <br /> ADDRESS ADDRESS <br /> PHONE PHONE <br /> ........................................................................................... . . . ..................................................................................... <br /> PLUMBER WELL DRILLER <br /> 0 <br /> ADDRESS ADDRESS 0 G1 <br /> O O <br /> ........................................................................................... ............................................................................................ O .i <br /> PHONE PHONE Z r <br /> DESCRIPTION 4. Sanitary Facilities: <br /> 1. Work: No. Bathrooms .......... CA <br /> 2. New Building Details c : o <br /> New Building Type of Construction: No. Bedrooms .......... 3 <br /> ..... <br /> Septic Tank Size GalsI E <br /> Addition . .......... <br /> .......... ...................... . ................... .. F . < <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... <br /> Filling/Grading ........ Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... Soil Type .................................... A <br /> 0 <br /> Mobile Home Slope .......................................... It ^ <br /> Privy3. Use (describe exactly, 1 -family <br /> IRate ................................... <br /> /�.�...... Dry Well j" ' <br /> Wellhome,garage, motel, etc.) """"" i <br /> Subdivision .......... <br /> Seepage Trench .......... <br /> .................................................... C' <br /> Camping Unit .......... u <br /> Seepage <br /> page Bed <br /> ------------------------------------------------------------------ <br /> Location of proposed structures and existing structures well,sewage systems, roads,etc., should be sketched in Fig A. Include road t Q :Z <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- 0 0- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> a <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> _________________________ _—______________—________—____ <br /> 5. Lot Size: / °C 'C Fi A. 6. Location: <br /> 9. <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... <br /> P <br /> N <br /> A <br /> N O <br /> O <br /> O <br /> O. <br /> 0 <br /> O <br /> 10 <br /> b S <br /> 131 T <br /> Z <br /> 6 � <br /> Z <br /> a is , n F <br /> N _. d <br /> a cn < m JG <br /> �t Z 0Dam <br /> 0 <br /> \ O p n <br /> \6e � 3 <br /> �LL7 - 7— �� �I <br /> a 7p <br /> . . <br /> . ..... ........ . . ..............................c........ ...................................... o : C_ <br /> Signature of Own�Agent Date <br /> X <br /> Remarks ......................................................................................................................................................................... m m <br /> v <br /> ....................................................................................................... . .................... ..... . . <br /> In <br /> Inspection Date ....................................... ' �' o U o U m <br /> 1%3 Zoning Admi trator K� 8 8 8 8 8 8 rn <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> before construction can begin. in the case of sewerage disposal systems, a copy of the percolation test must be 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 bLllld- <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 lie made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />