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Burnett County Office of Zoning Administrator 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3 :3 <br /> TO THE ZONING ADMINISTRATOR'. The undersigned hereby makes application for a Permit for the work described and located as — 2, <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use <br /> IQ <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. a <br /> eTe iN � ° <br /> G � .... e..w.A..�'�). ....usse.l .g,� ......... .......... .. 8 5�.. ............... H <br /> ..... ...... ........... ..... ... <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT af° <br /> STitfi' rj'7f <br /> &x' 3....5 .......S oe.v�,� . . . . . ................................................................................. a <br /> Z l <br /> .... ........... <br /> ADDRESS ADDRESS <br /> .............. <br /> ... ........................................................................ . .. .. ................................................................ . <br /> ............... . <br /> ADDRESS ADDRESS... .... .. ' <br /> 1p35- .��.................................................. ............ <br /> ................ .......... <br /> PHONE PHONE : or ; viln <br /> ............. <br /> ........................................................................................... ............................................................................... <br /> PLUMBER WELL DRILLER <br /> p <br /> ADDRESS ADDRESS m G1 <br /> o <br /> (� <br /> ............... . ...................................................................... ............................................................................................ o jam) <br /> PHONE PHONE ° ' <br /> r � <br /> DESCRIPTION 4. Sanitary Facilities: o <br /> 1. Work: No. Bathrooms ' <br /> 2. New Building Details """"" o <br /> g Type of Construction: <br /> New Building X No. Bedrooms .......... " a° <br /> .......... ....................................... <br /> Addition ...,,..... ............. Septic Tank Size Gals. .......... <br /> . <br /> Sanitary .......... Size ....2..q.. ft. x ... : ... ft. .......... <br /> . i <br /> Filling/Grading .....I.... Height........... Stories ......... 4a. Absorption Field Site: i <br /> Moving Area ....................... Soil Type .................................... <br /> .......... ................... o <br /> .......................................... <br /> Mobile Home ........., Slopenu : - <br /> Privy .......... 3. Use (describe exactly, i -family Perc. Rate ................................... ¢�, <br /> Well y ; rJ <br /> ,.,,,,,,,, home,garage, motel, etc.) Dr Well .......... �, <br /> Subdivision G R.Ctm Seepage Trench .......... <br /> .......... ................. <br /> Camping Unit .......... Privy <br /> .................................................... <br /> Seepage Bed .......... ; <br /> ---------------------------------------------------------------------- <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig. A. Include road i Q <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- n, a. <br /> 0:1section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING � < a <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. <br /> �pror A VobPrS <br /> er, <br /> n <br /> N o <br /> O <br /> �n w^ <br /> .7 ,\ <br /> 71 <br /> Z c <br /> O <br /> 71 <br /> � A <br /> n r 1 N m Z <br /> c d < d c m <br /> m OE- n = n F <br /> .�' so <br /> (Nit < C m <br /> o N m a m <br /> z o o a <br /> vi <br /> D <br /> 1/ <br /> N <br /> Signature of Owhdr"Or Agent Date — <br /> x <br /> i v <br /> Remarks .................................................................................................................................. <br /> oa <br /> ........................................................................................................................................................................................ — <br /> .. . ,! <br /> ............ <br /> ....... .............................................................................................. ..... .......... . <br /> MMM <br /> Inspection Date ...............................:....... .... .. . <br /> /..�.... ................................ us <br /> Zoning Ad istrator :� : $ 8 0 0to <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary fdcIIItI Os <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 if misrepresentation of any of the information conveyed here- <br /> with is found to exist. Changes in plans or specifications shall not be made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />