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C�J'7 C�C9y�tom.. <br /> Burnett County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT0 3. <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work describe and '� 0 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements f the $ C �r D <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the law and 3 Q 'T <br /> regulations of the State of Wisconsin. �' <br /> m ''� <br /> w <br /> NEW'G..Wp'r'jlllj�e he..d....................................... ............. ...........................................................T...................... ........ P^ m <br /> OWNER (please print) _ CONTRACTOR or SURVEYOR or AGENT <br /> .R'0..,...6.'s.x...... 8,t.....5..�4.Tts...�.►.�.g....G r o. <br /> .. . . ........................................................................ ........ o. <br /> A�RE�SSS� ADDRESS <br /> . . . ................................................................................ .A......RESS... . . ................................................................... ........ W, 1 <br /> ADDRESS DD ^n ' <br /> LI > <br /> PHONE'. .•'..7.. ..7.. .b..(.) .................................... .PHONE.......................................................................F........ <br /> .....(�...1't4. ...................................................... . . ...........................................................L........ ; <br /> PLU BER WELL DRILLER <br /> `o E4 <br /> ADORES$ ADDRESS m 0 1L <br /> n o <br /> o .. <br /> PHONE PHONE Z r <br /> DESCRIPTION 4. Sanitary Facilities: P o <br /> 7. Work: 2. New Building Details No. Bathrooms <br /> Jo <br /> New Building Type of Copstr ction: No. Bedrooms .......... �- <br /> .......... [yJ <br /> Addition ,- ., P„}o(, ,r,++.,.0 Septic Tank Size Gals. ....5 Q - <br /> Sanitary ..... Size .............. ft. x .............. ft. ........ <br /> •' <br /> Pillingl Grading 4a. Absorption Field Site: <br /> .......... Height............. Stories ............... <br /> Moving Area Soil Type .................................... :or r <br /> .......... ........................................... <br /> Mobile Home Slope •� <br /> Privy .......... 3. Use (describe exactly,'1 -family Perc. Rate ................................... <br /> n <br /> Well .......... home,garage, motel,etc.) Dry Well .......... :Z <br /> Subdivision ,,,,,,,,,, page Trench Z i <br /> Seepage <br /> .......... O <br /> Camping Unit .......... .................................................... Privy <br /> .................................................... <br /> Seepage Bed .--- <br /> te <br /> Location of proposed structures and existing structures well sewage systems, roads, etc., should be sketched in F g. A. _ r"I <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at t <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. i"^1 –' <br /> 5. Lot Size: Fig. A. 6. Location: O. `d <br /> ................ ft. x .............. ft. . ............................... sq.ft. ..................................................................... ......... <br /> hoytL <br /> o r <br /> 0 <br /> 'm a <br /> d <br /> N <br /> rOJ4 <br /> D fD fD� <br /> m_ Nnnm a a M <br /> 9 !y <br /> o N n <br /> o c m <br /> v O <br /> ........................................................................... A <br /> Signature of'Owner <br /> /or Agent Date o <br /> Remarkst%of95./T-./C ..C- U.`."�/!�.. ................................................................................................................... ..... '- n <br /> ........................................................................................................... <br /> .......................................................................................................... ................... ........ . (T� <br /> ...... . <br /> Inspection Date .7-1:–.Z7.......... ..l..r....�:T4UN.tA,V c, m <br /> Zoning Administ or L.... g $ S g N <br /> NOTE: A preliminary site inspection must be made and site approval 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 app ication 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 ANDA PROVED. <br />