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Burnett County Office of Zoning Administrator 1 0 0 <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 and located as — O <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use V <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> —' <br /> — m <br /> A. �.�.1. N ..... lc. E <br /> � <br /> �. .a .� ..... . ............. ................. ...... ............. ...... ........ . . ................................. � <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT m <br /> `r ...i{..1 ..O..tJr......4.4'.r..... rb <br /> ............................... <br /> .............................. ............................................................. <br /> I A RESS ADDRESS <br /> �rsc r . t.t. ..�..........�5".y°..Z...�....... ............................................................................................ [ <br /> ADDRESS ADDRESS Y iF <br />�rPRION................................................................................... .PHONE................................................................................ `\ <br /> 9 <br /> 5 ........�.. .....�`�.. . ....................................... ..WE............R.I..LLE.L'EI.R.................................................................... <br /> PLUMBER LL D \ ?4�?all, <br /> ........................................................................................... ............................................................................................ .p <br /> ADUR ESS ADDRESS <br /> n o q <br /> A ........................................................................................... ............................................................................................ <br /> PHONE PHONE Z <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms .......... '� ' ' <br /> 2. New Building Details o ; <br /> i No. Bedrooms ..... :tel a <br /> New Building Type of Construction: ;\ ci <br /> AdditionSeptic Tank Size Gals. .......... :p <br /> .......... .................................................... <br /> Sanitary <br /> ...,10... Size t.... ft. x es ya <br /> ........ ft. .....•. <br /> . Absorption Field Site: <br /> I. <br /> Filling/Grading ,,,,...,,. Heigh ......... Stories ............... <br /> Moving .......... Area ........................................... Soil Type .................................... r i <br /> "1 <br /> Mobile HomeSlope .......................................... <br />' Privy ,,........ 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Well .......... home,garage, motel, etc.) Dry Well .......... fJ :h <br /> Subdivision .......... .................................................... Seepage Trench .......... SZl i6 <br /> Camping Unit .......... Privy .......... Gj i <br /> .................................................... <br /> Seepage Bed .......... , <br /> Location of proposed structures and existing structures, well,sewage systems, roads, etc., should be sketched In Fig. A. Include road <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- a <br /> section, show the Intersecting highways and the setbacks required along them and at the Intersection. CLEARLY LABEL EXISTING I1 <br /> A <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. Wp <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: r 6 <br /> ................ ft. x .............. ft. — sq. ft. ... <br /> u <br /> o r L <br /> A <br /> a <br /> r � a <br /> a <br /> N <br /> � r'C" r qv <br /> c w 13a m z <br /> N m n m <br /> m <br /> m <br /> ............... ..... ............ ..... ..... ....... ..... . ... ..... . ...... .... ... ..... <br /> Signature of Owner or Agent '�o C <br /> Remarks ..rS.E� ?: /?Ar/ :.:.. .. c:. ... .... .. . .... .. . x C <br /> � ' <br /> ........................................................................................................................................................................................ :� II . . . <br /> ................................................................................................... -n <br /> ............. ... .............. ... ..........................I................... :Ut <br /> D: <br /> ern <br /> Inspection Date ....................................... m <br /> Zonin ministrator 8 8 <br /> 8 rn <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary tacil illus <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 build- <br /> ing until a permit has been Issued. A permit may be revoked it misrepresentation of any of the information Conveyed here- <br /> with is found to exist. Changes in plans or specifications shall not he made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />