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Burnett Cout9ty Office of Zoning Administrator <br /> -APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3• 11J <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 i— <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the Stateof Wisconsin' 3 g <br /> n...................................... ................................... .....................................................................................1...... ddd <br /> OWNER (please print) CO RACTpy or RVEVOR or GENT <br /> "" g+� K <br /> . .4. G.. ....... !. o � ... . /J1. ......... �t�..N...ti.l..�✓. ../...... ........a....... <br /> CL <br /> ADDRESS... .. .... .. ........................... .ADDRESS ' <br /> ..r.......�.......w....�.. s.... R................ ........I............. ,.. ........... .... ...... <br /> ADDRESS L ADDRESS <br /> i <br /> ..... .. .9.3.................................. ..... . . . ...... : , <br /> . . ......................................................................... . <br /> PHONE PHONE {y` <br /> ..................8..�...�.......`.:i 41...7../................... ...................... . ..-..2.:x..1/................ ....... ° <br /> PLUMBER WELL DRILLER <br /> O <br /> ADDRESS ADDRESS n O <br /> ........................................................................................... . . ................................................................... <br /> Z....... ....... ' N '1 <br /> PHONE PHONE...... .. r <br /> DESCRIPTION 4. Sanitary Facilities: ° o 0 <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details •• ....... o' <br /> New Building ,,,,,,,,,, Ty a of nstructi n: No. Bedrooms ..'�.... <br /> Addition „1-'4, ,�(�`1�,,,,�, „c,�„-�t✓„p,QM Septic Tank Size Gals. .. ....... <br /> Sanitary .......... Size ...2:�1.�. ft. x .....2..Q... ft. .. ....... <br /> Filling/Grading ........., Height...3....... Stories .....I........ 4a. Absorption Field Site: <br /> Moving .......... Area Soil Type ..................... <br /> ....... <br /> Home Slope ........................... . ... <br /> v <br /> ` o <br /> .......... ....... i <br /> Privy 3. Use (describe exactly, 1 -family Perc. Rate ........................... I...... � i <br /> Well .......... home,garage, motel,etc.) Dry Well .......... T <br /> Subdivision .......... Seepage Trench .......... 0 <br /> Camping Unit .......... Privy .......... <br /> .................................................... Seepage Bed--------------------------------------------------------------------- ' <br /> 1 <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 loca ed at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersec ion. < <br /> vt <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. t o <br /> __________________________________ —_______________________________ __ i <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ....................... ....... sq.ft. ...................... ............... . ... ............ . I i <br /> -30 <br /> O i g 4rA' ` tlJ.) 0 <br /> I <br /> y X 20 Z <br /> 2Z <br /> — o <br /> J <br /> S � �1do2 <br /> AEM ;.NT CJ <br /> �— l z�-1 l r <br /> AGpuT <br /> /S <br /> ll v D <br /> 0 Z. 0. 0. .0 cm E <br /> . <br /> rn <br /> G00t nJA TTL/ /N mm nn> y_irn <br /> ZAkhoinO ,2 D <br /> rn O. W a p <br /> m <br /> a o . O <br /> n . m m <br /> Signature of Owne r <br /> .... .. A ' <br /> ..Dategent <br /> R � <br /> . . ..... ...... ��0� J. 7................ ........ .......... <br /> . �........... r/....... - ..... . ...... HT <br /> ............................................................................................................ ...... ................... . ........ o <br /> N D N 'n <br /> Inspection Date ....................................... .'r��-....h..... o an o o . m <br /> Zoning Administrator g g $ g N <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary N cilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this app ication 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 beE n 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 AF PROVED. <br />