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Burnett County Office ofZoning Administrator 0 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> 0 <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as < <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 M <br /> Monroe T. Blorngren iCf f <br /> ..................................................................... ............................................................................................ <br /> OWNER Iplease print) CONTRACTOR or SURV EVOR or AGENT o. :t <br /> Rt. 1 Box 180 — m <br /> ........................................................................................... . ................................................................. .. <br /> .. .................... a <br /> ADDRESS AD.. DRESS is ::X <br /> Grantsburgt WI 54840 ?o <br /> ............................................. ...... <br /> ADDRESS ADDRESS..................................................................... i(D <br /> ....Donald Daniels .... ........ . . .. . .. . . ................... •3 <br /> PHONE................................................................................ .PHO...NE............ ... .... ..... ....... ...... ..... ..... . <br /> Box..wSiren <br /> ................ yJ <br /> :r <br /> :o <br /> PLUMBER WELL DRILLER :. :IS <br /> .....7.1.5-.4.63-233.3.......................................................... ................ ...... <br /> ADDRESS ADDRESS i L) <br /> O <br /> ........................................................................................... <br /> ............................................................................................ O .: <br /> PNONE PHONE Z H ' <br /> DESCRIPTION 4. Sanitary Facilities: o o 0r <br /> 1. Work: 2. New Building Details No. Bathrooms ...1...... o <br /> New Building ....... Type of Construction: No. Bedrooms ..a...... -o <br /> Addition ,......... Septic Tank Size Gals. ...,...... i <br /> ......................... ..x ................. .. Holding Tank 20BS.... <br /> < N <br /> Sanitary .....X... Size .............. ft. x ............., ft. <br /> FillinglGrading .,,,,..,,, Height............. Stories ............... 4a. Absorption Field Site: p i <br /> C] <br /> Moving Soil Type .................................... r- <br /> .......... ' <br /> Mobile Home Slope ............................ ......1...... C 0 <br /> .......... <br /> ...... 'c* <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ... ............."' ' �""" <br /> Well .......... home,garage, motel, etc.) Dry Well <br /> Seepage Trench -A- p <br /> Subdivision ,,,,,,,,,, <br /> Camping Unit .......... .................................................... PrivyO :mo m <br /> Seepage Bed C- : - <br /> —————————————————————————————————————————————————————————————————————— <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- 4— a <br /> section, show the intersecting highways and the setbacks required along them and at the Intersection. CLEARLY LABEL EXISTING p :O <' <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. i � 0 <br /> - <br /> 5. Lot Size: Fig. A. 6. Location: ii" E <br /> :C <br /> ................ ft. x .............. ft. — sq. ft. , <br /> P <br /> n <br /> N O <br /> o <br /> See State approved plans o <br /> 0 <br /> v <br /> . : T w <br /> 2 <br /> { O <br /> t � d <br /> r+ <br /> <p m <br /> M 00 U m so <br /> O an O. C <br /> m <br /> 0 0o im 3 <br /> ��/// En <br /> Y J wo — <br /> i <br /> ......................... �] ` = p <br /> /......r .- ` ...... 0 <br /> 0 <br /> Si azure of Owne✓r or Agent Date o C <br /> Remarks I x m <br /> C ( C r. •. .. i—..................................................................................................................' 'n v <br /> A ' <br /> II <br /> .......................................................................................................................... .... ... ........... ........................................ . <br /> to T <br /> Inspection Date ( ��...... ` G? 7 l ;.......tX�'12( y1. : 8 o m <br /> P ✓// <br /> ............... ...... <br /> Zoning Adm-mi trator <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary faculties <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation best 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 />