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Burnett County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3• <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described nd •2 p 0 . <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the ,$ c <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws nd 3 :I <br /> regulations of the t to of Wiscons1 3 <br /> 'A.rQ.K.......k ...B.t�.i^... cen........ ...-y�.` ..............C. !..5.: ................................. ...... A <br /> OWNER (please print) �' CONTRACTOR or SURVEYOR or AGENT <br /> J.alb....... .e!/5.....D.!..•.................................... .................................................................... ................ ...... <br /> .......... ....... <br /> ADDRESS ADDRESS � � t O <br /> Vit IS...:.. .. .n.............S5y3S Pb 1cr �e �( - <br /> . ............................... ................5................. . <br /> ADDRESS ( ADDRESS (C�) <br /> : 1 <br /> ........................ ...................................................... .PHONE.................................................................................... ...... i� <br /> PHONE p <br /> PLI�T.,.�n......... /57 .Y. jr................................... .WELL DRILLER............................................................ . <br /> ......... ..]1:. Pi............11.Y..�. ............................. . ...... . . ........................................................................ ...... rr <br /> ADDRESS ADDRESS ' .LO <br /> 6a.8................................................ ..................................................................................... ...... o <br /> PHONE PHONE <br /> DESCRIPTION 4. Sanitary Facilities: P 6 00 <br /> 1. Work: No. Bathrooms `O <br /> 2. New Building Details ••• • �• f�� <br /> New Building X Type of Construction: No. Bedrooms ... ..... d J <br /> .......... i <br /> Addition Septic Tank Size Gals.F.. 1.0t.12.� ......................... <br /> Sanitary <br /> ...x.... Size .............. ft. x .............. ft. .. ....... : <br /> Absorption Field Site:Absorp <br /> Filling/Grading .......... Height............. Stories ............... 4a. <br /> Moving .......... Area Soil Type ....... ...... J" \ r.. � i <br /> Mobile Home Slope <br /> ...................... <br /> .......... <br /> Privy 3. (describe exactl ffamil �_ <br /> . .. Perc. Rate ......�-............ .. ....... <br /> Well ho g rage, mote ,e Dry Well : a <br /> .. ....... — N <br /> Subdivision " M Seepage Trench o ' <br /> .......... .. ....... <br /> Camping UnitPrivy <br /> .......... .................................................... a� <br /> -- — <br /> Seepage Bed .— R{" <br /> Cn <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fill. A. g <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is local d at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersect on. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> 5. LoSize: ,�Q� Fig. A. 6. Location: <br /> .�............. ft. x :............ ft. . ............................... sq. ft. ....................................................................... ..... <br /> 1 <br /> 0 <br /> o <br /> 0 <br /> 0 <br /> 7 <br /> I � a <br /> .z 'Z o <br /> 0 <br /> d <br /> o " <br /> �J <br /> 1� <br /> A c roN n c_ m <br /> m_ Nii < � ny an � <br /> Qy y 0 m m 3 <br /> W O D <br /> O D > <br /> N <br /> o c m <br /> a : 0 <br /> .1..... -........... ...lo .-...Z(C-..V.. x o <br /> ...... a <br /> Signature of Owner or Agent Date '; e <br /> Remarks�(.. ....�C:..............:............................................................................................................................. .... <br /> u <br /> �BRNooNm <br /> Inspection Date ...md........ .... ................ ......... m <br /> Zoning Administrator 8 8 8 8 8 8 to <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this appl cation 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 beea issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or 3pecifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />