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Burnett County Office of Zoning Administrator IP g�g <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3• 9 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and <br /> '� M <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws land ' <br /> regulations of the State of Wisconsin. 3• a <br /> OWNER (Please print)(,""'••••.••"'.....•••• •. "•'•• •'••••'••.••..'.."' CONTRACTOR or SURVEYOR or AGENT <br /> ........;BOX.......�.�.j. j ') <br /> ADDRESS ADDRESS...................................................................... ...... S' . <br /> ................ <br /> ............................................................. <br /> Poll) ( / i <br /> ADDRESS / ADDRESS F ?6 <br /> PHONE PHONE \� 1 <br /> PL.U. MBER . ...... . .. . ........................................................ �i...... <br /> WELL DRILLER ........ <br /> ; <br /> ADDRESS ADDRESS o <br /> ........................................................................................... . ........................................................................... ...... p <br /> PHONE PHONE......... Z ar <br /> DESCRIPTION 4. Sanitary Facilities: P o <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details ••••••'•• p' ' <br /> New Building No. Bedrooms ..i...... <br /> .......... Type of Construction: <br /> .. R `• <br /> Addition 1/ ....;f;rqk... ............................. Septic Tank Size Gals. .......... •� <br /> Sanitary .......... Size .....5 ...y ft. x ...^ r�,.., ft. "'"""' i i i iQl <br /> / <br /> FIIIIngi Oreding .......... Height.... ... Stories ............... 4a. Absorption Field Site: <br /> , <br /> Moving ....... .. Area ./.7..4.....4y.....ff. Soil Type .................................... <br /> Mobile Home .......... Slope .......................................... <br /> Privy .......... 3. Use (describe exactly• 1 -family <br /> Perc. Rate ...........................�....... m <br /> Well •......•.. home,garage, motel,etc.) Dry Well ..a....... m i <br /> ...Rdr/r.tl. '�....:A.f.fl..... — — Seepage Trench I <br /> Subdivision n..•,•• 1 ••1••••••• Z <br /> Priv ..�....... <br /> CampingUnit .......... ............................................. . .... y <br /> Seepage Bed 1 <br /> ----------------------------------------------- -------.T-- . l •y ^ <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fi A. \, 1 <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is locat d at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. LCLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o � <br /> -------------------- <br /> ----------------------------------9 A. 6. Location <br /> ------------ -- :Q [ .' �m <br /> 5. Lot Size... ft. x .............. ft. — ............................... s*.f ^ — <br /> ' . . . ... ....................................... <br /> 12, <br /> i E 20 �30 'and_ ,b�/001� 0CY o <br /> ( SHel S/ <br /> o <br /> Hos f <br /> 0 <br /> T <br /> M <br /> _ <br /> oZ <br /> D <br /> m <br /> Enr­ <br /> \` <br /> I!I <br /> pl v 0 0 D OO W m <br /> m, U1 <br /> of v c mCygg ; <br /> grn '2 � om - <br /> H n . <br /> fY1ai s'F- <br /> a : y <br /> In <br /> 0 0 <br /> o _ <br /> A : o <br /> `�� .....qr ................ ....g-. $ ............. <br /> x <br /> Signature of Owner or AgenDate ' <br /> g : <br /> Remarks M y <br /> o : <br /> ......................................................................................................... ......... ... . g ; <br /> ... ......... .........9................................. <br /> Pn NOON + � m <br /> .... .....r u u v o m <br /> Inspection Date ....................................... PP 9 tonin Admini ato9 �'• L. . . <br /> ggg S N <br /> NOTE: A preliminary site inspection must be made and site a royal ranted on all structures involving sanitary fa lilities before construc i <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this app)' ation 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 bee issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or pecifications 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 />