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Burnett County Office of Zoning Administrator o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT - 3 <br /> _ o <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as u, <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m C <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> g 3. <br /> WjIITarn. leliclear -. ...�e ......�1.�. .Q ............................. <br /> ........................................................................................... ......... <br /> OW R (pee print) CONT TOR or S VEYOR or AGENT a `, <br /> 1. 1.1... nil... .(we ................................. . ..� . ..>..!..,....���e�C...J���................................ � <br /> AM D.8 EBB ADDRESS m Q <br /> .. x....535.. .......... r� .................... t11'' <br /> ADDRESS ADDR iW <br /> ........... . . . . .. . ......................................... . .......................................................................................... <br /> . ..... .... .... .. .... ............ <br /> PHONE PHONE <br /> PLUMBER............................................................................ 'WELL DRILLE..P......... ......................................................... _ n <br /> O <br /> ........................................................................................ . . .............. _. <br /> ADDRESS ADDRESS n o <br /> ....... ............... <br /> ........................................................................................... . ................................................................... . <br /> PHONE PHONE <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> 1. Work: 2. New Building Details No. Bathrooms .......... o <br /> No. Bedrooms """"" <br /> L ' — <br /> New Building .......... Type of Construction: t° <br /> Addition Septic Tank Size Gals. .......... <br /> .......... ................................................. .. <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... ;n�( <br /> FillinglGrading .......... Height............. Stories ............... 4a. Absorption Field Site: i <br /> SoilType .................................... r <br /> Moving .......... Area ......................................... 0 <br /> 0 <br /> Mobile Home .......... Slope .......................................... <br /> Privy .......... 3. Use (describe exactly, 1 -family Fare. Rate ................................... <br /> Well home,garage, motel, etc.) Dry Well A <br /> Subdivision Seepage Trench .......... <br /> Camping Unit .......... .................................................... Privy ......... p � <br /> Seepage Bed ......... Y . <br /> ------------------------------------------------- ad <br /> Location of proposed structures and existing structures,well, sewage systems, roads, etc., should be, sketched in Fig. A- Include road rQ <br /> setback, side and back Yard dimension and location and setback from all bodies of water. If property is located at a highway inter- o: <br /> section, show the Intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> 0 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. Q o <br /> 1-----------------__------_------_-- --_------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. fi. — ............................... sq. ft. .............................................................................. ' <br /> 3� <br /> �. <br /> h2cl N ° <br /> 0 <br /> _ <br /> I m <br /> N <br /> z <br /> O <br /> v <br /> _ <br /> m <br /> M r- 9 :E yr m Z <br /> < — F <br /> m N < — y nM -0 <br /> m <br /> = m <br /> z o n 7J <br /> Wo � <br /> ............ .....1.D..- .-. ......... p <br /> Signature of Owner or Agent Date <br /> X <br /> „ : m <br /> Remarks ......................................................................................................................................................................... .� : p <br /> : <br /> e» <br /> ......................................................................................................... ...................... ............................................... �1//�'11 : : T <br /> Inspection Date ....................................... . . [ ,... ..TdA%IGL. . . ij:/.!.t_...r.. �'^ $ 0 8 0 0 8 M <br /> � m <br /> ZoniCn <br /> ng Adminis for <br /> o � m <br /> NOTE: A preliminary site Inspection must be made and site approval granted on all structures invol ing sanitary facilities <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attacher) to <br /> this application before a permit will be issued. Do not purchase or install a septic tank, do any plumbi ig 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 hero <br /> with is found to exist. Changes in plans or specifications shall not be made without approval of the Zoning Adm inistratol . <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />