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0 <br /> Burnett County Office of Zoning Administrator fC e <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 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the ,� 4 <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and d <br /> reg u tat onaoIthe Statepf Wisco n. 3 <br /> -T r1U - m <br /> OWNER\Iples»printf........try..�t../..dy.................................... . ..................:5 ...(.. ......................................................... <br /> CONTRACTOR = r' <br /> or SURVEYOR or AGENT <br /> SIn99-11 :H <br /> cN l...tf.......1.. .. a Ea <br /> ADDRESS ADDRESS m <br /> ................................................................ ..... . ........................................................................................... l <br /> a. <br /> ADDRESS . . .... ........... .ADDRESS <br /> ........... .. ..................................................................................... .gq ...�Q .. <br /> PHONE PHONE <br /> 11 �.e •��t'ri n f <br /> .. .. .. ..................................................................... .................. ......................................................................... <br /> PLUMBER WELL DRILLER �T <br /> ........................................................................................... .AD.. ..D. ..RES-'E'S".............................................................................. : O <br /> ADDRESS S m 0 <br /> n < <br /> .P..H..ONE.. ... ................................ ........ ............................ �„ <br /> ........... <br /> PHONE Z , r- <br /> 0 <br /> DESCRIPTION 4. SanitaryFacilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms '— c <br /> New Building ....6.f..., Type of Construction: No. Bedrooms <br /> •••�•••••• R <br /> Addition .,, Septic Tank Size Gals. ........ I <br /> SanitaryT� Size ... 3IA.... ft. •S•�• <br /> .......... al.'�.... ft. x Stories <br /> 4a. Absorption Field Site: <br /> Fillingl Gradlnp .......... Height............. Stories ..../........ <br /> Moving Soil Type .................. <br /> .......... ........................................... .................. r i <br /> o <br /> MODIIs Home .......... Slope .......................................... <br /> Privy .......... 3. Use (describe exactly,'1 -family Perc. Rate ................................... <br /> m <br /> Well .......... home,garage, motel,etc.) y <br /> Dr Well .......... m <br /> SuDdivlalon ,,,,,,,,,, ,.,� fad.-r !J' Seepage Trench z <br /> o :/1h <br /> Camping unit Seepage Bed <br /> Privy :� > <br /> ----------------------------------------------------------- - -- __ N [\ <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Cf <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at :In g <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. 3- `- <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. :a o <br /> ___ ____ ___ :p <br /> 5. Lot Size: Fig. A. 6. Location: `f1� <br /> ..�.l.d..... ft. x ...1.6.r... ft. - ...: L od.......... sq.ft. ............................................................................... <br /> p <br /> N O <br /> � o <br /> � D <br /> a <br /> Z €z <br /> 0 <br /> ?J <br /> 07) p01- Dt0 m 10 <br /> n fnQ <br /> . . . . . . rn <br /> icy > > 3 <br /> O y 'c ur O m u7 <br /> O fR O •G D <br /> U N o . <br /> o c rT <br /> 62 . ... ...... ....................... ......lf. /..I..... .�!...... n o 0 <br /> Signature of Owner or Agent Date o <br /> I- <br /> .... r` .F. <br /> cr <br /> Remarks .......................................................................................................................... m' <br /> m ;. <br /> m �• <br /> v <br /> o : b <br /> .......................................................................................I........... .'........... <br /> .. ...... .. //,,, <br /> , ..........�. ........ <br /> ............ <br /> I_ `^ l � <br /> . . . a n <br /> Inspection Date ....... ............................. WTUWNo ' m <br /> Zonin9Administ $ $ 0 8 <br /> fA <br /> NOTE: A preliminary site inspection must be made and site app oval 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 application 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 been issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or specifications 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 />