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er X)L�. <br /> Burnett County Office of Zoning Administrator 0 0 <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 located as H �� <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. 3 a <br /> ��a . .�... <br /> o <br /> ..T.l..l-..........X7;1 ../...N..:...`....— ........... ............................................................................................ <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT <br /> ........�..; ...!.............�:7.:r.....� . ........1.� �........ . ID........... ... <br /> ADDRESS 7 ' <br /> ADDRESS <br /> .r S <br /> 1 <br /> l / 3s..�..... .........................................................I.................. :. . ........ <br /> s <br /> ADDRESS ADDRESS �r•�. �^ � ' <br /> L <br /> _ o „ r) <br /> PHON PHONE r <br /> .......... f .4 .. /��n � <br /> PLUMBER WELL DRILLER <br /> .... ..... .:... ...................................... <br /> ........................................................................................... ........................................................... ..... .. . ................. �i, -0 <br /> ADDRESS ADDRESS m C7 <br /> n o <br /> ............. <br /> ........................................................................................... .PH....ONE.. ... ..................................................................... <br /> PHONE <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms o <br /> New Building ,,......,, Type of Constandi iq4 No. Bedrooms .......... <br /> Addition .. .....•-.�.�...,){/, .>S./..i,.h.. .......... Septic Tank Size Gals. �I r <br /> Sanitary ... .. Size .......6...... ft. x ..... ..... ft. til C l: s........... :�. . F. <br /> 4a. Absorption Field Site: - h, <br /> Fillin (Gradin .......... Height............. Stories ............... / <br /> Moving g .......... Area Soil Type ................JyO„/,...... <br /> ......................................... ./ <br /> Mobile Home .......... Slope .. <br /> ........................................ F <br /> Privy Pere. Rate ................................... <br /> .......... 3. Use (describe exactly, 1 -family ;^ <br /> Well .......... home,garage, motel, etc.) Dry Well .......... fi r i <br /> Seepage a e Trench .......... t{ <br /> Subdivision <br /> .......... .................................................... <br /> --Camping UnR— Privy .......... <br /> .......... .................................................... T <br /> _________ Seepage Bed____________ <br /> o o• <br /> Location of proposed structures and existing structure§_well, sewage systems, roads, etc_, should be. sketched in Fig. A_ Include road <br /> C C rT W <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway Inter- ` i section, show the intersecting highways and the setbacks required along them and at the intersection_ CLEARLY LABEL EXISTING ° <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS, U ° 0 C <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................. sq.ft. ............................................................................... <br /> N o' <br /> 0IAN <br /> k V <br /> I o 0 <br /> i1 F <br /> J <br /> I � T <br /> 0 <br /> o <br /> `� <br /> I <br /> _ <br /> Z <br /> <I Z <br /> 1 <br /> m N a m _, <br /> cn <' C ,�I c 'O <br /> o ^. y m <br /> '_ n <br /> 0 of na � 77 <br /> 73 <br /> � o <br /> €tet , a <br /> m <br /> .. �.......... ; , p <br /> .................. ..... ................... ° C <br /> Signature of O e�or Agent Date <br /> fit// . . . . <br /> GO J E'G m x m <br /> Remarks ... ................................................................................................................................................................. <br /> m <br /> Efl <br /> ........................................................................................................................................................................................ <br /> ....................................................................................................... .. <br /> N o: H T <br /> o............ .................... ........................................... <br /> Inspection Date ......:/..`a ._✓. 6....... �(,2,.,u✓/...:. �L�CL�C� L,tJ ...... ............. U �'0 8 0' m <br /> . . .... ......9... � .. ... <br /> Zonin Adi'(inistrator I ) 8 8 8 8 8 N <br /> NOTE: A preliminary site inspection must be made and site approval yranted on all structures involving sanitary tacilitieS <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 /> yea vee <br />