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o' i; <br /> Burnett County Office of Zoning Administrator 0 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3 o <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as < H :p <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use c <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. cL <br /> It <br /> � t N o <br /> rat J ................................................... ....... . . . . . ........ . .......................................................... <br /> ... . . . . ... <br /> OWNER (pleasgg,pnt) // CONTRACTOR or SURVEYOR or AGENT n <br /> 3.`f ...1` !.hc04q _ <br /> . . .................. . ....... ............................................................................................ rs <br /> ADD RES .` <br /> ADDRESS <br /> , .......... .........rf/.V ...... a <br /> ADDRess .. ADDREss �c <br /> '..�...G..` .`I...'....G.7...7.°�'...................... ........... n Q�� <br /> ................................................................................. <br /> PHONE PHONE <br /> ........................................................................................... .WELL..........DR.....ILLER..... R................................................................... <br /> PLUMBER <br /> O <br /> ADDRESS ADDRESS m L) <br /> 0 < <br /> ............... . . .................................................................... ............................................................................................ o <br /> PHONE PHONE Z <br /> DESCRIPTION 4. Sanitary Facilities: ° o .( <br /> th <br /> Barooms `F <br /> 1. Work: 2. New Building Details No. <br /> New Building CC No. Bedrooms z <br /> ...x.. Type tion: .......... <br /> aG .R 0i Septic Tank Size Gals. .......... .« <br /> Addition ... .. .. ...... ..........�,...... .... .........�t . .. .c <br /> Sanitary .......... Size .....�.42.... it. x. a'(.....ft. .......... . <br /> Filling/Grading .......... Height../A..... Stories ............... 4a. Absorption Field Site: i <br /> Soil Type ................................. <br /> C' <br /> ... <br /> Moving .......... Area ........................................... Soo <br /> Mobile Home .......... Slope .......................................... <br /> Privy .......... 3. Use (clesclillalexactly, 1 -family Pere. Rate ................................... <br /> Well .,........ home ora , motel, etc.) Dry Well .......... <br /> Seepage Trench .......... i <br /> Subdivision .......... .......... ..... ..�............. Privy 1_ . <br /> Camping Unit <br /> .......... .... .......... ..... .. ...... <br /> '� �� Seepage Bed .......... I <br /> Location of proposed structures and existing structures, well, sewage systems, roads, eta, should be sketched In Fig. A. Include road <br /> setback, side and back yard dimension and location and setback from all bodies of water. It property is located at a highway inter- I O- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. no LABEL EXISTING < a <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. ��• o <br /> _----_____________________________________________________________ <br /> — 1 i <br /> 5. L Sz8. 00 Fig. A. 6. Locatio nyr__ <br /> ., . ........ ft. x .�.......... ft. . ............................... sq. ft. ............................. .o............ Ct............., <br /> to <br /> Ile <br /> , <br /> e <br /> s <br /> C_ 4 <br /> T Q <br /> N <br /> Z <br /> O <br /> /l AAy <br /> C <br /> Q) r to Z <br /> f( <br /> n Q � < <br /> M a c^tn < C d g .9 <br /> o m <br /> E» _ <br /> Signature of Owner or ate <br /> X � <br /> m <br /> Remarks ......................................................................................................................................................................... m.n � p <br /> m <br /> Va <br /> ........................................................................................................................................................................................ — <br /> II <br /> ......................................................................................................... ... ...................... . . . . . . <br /> d : <br /> // /fU � ogo � m <br /> InspectionDate ....................................... . Qtrn,l�.,(.�..... ...... .... •...... ........................ m <br /> ZoningAdministrator '0 0 0 0 o 0 <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <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 />