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Burnett County Office of Zoning Administrator tC c <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 ,S c kO <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the Sta fWisconsin. <br /> ,r. ............................. ... ' . . . ... ne .......\ �..c�J� i� - <br /> OWN E Iplesu print) CONTRA OR or SURVEYOR or AGErgT q <br /> .................... .. . I......... ...........X........ .................. el...x.1\ g ......................................................... .... a —� <br /> AD RESS I ADDR S O1 <br /> (�It"_�I ' ✓,/ �/��� �-I{(p� I I nIt'�C�n 11 1�5.jl�'�v}l ... <br /> ADDRESS <br /> Lv`M1.l .Y .L.K 4J�......v..f..:! ............... .ADSr���...`! .... ..1:?...1. ........ . I <br /> / 1 i <br /> ........................................................................................... .P.HOH.0. N..E.............................................................................. .... <br /> PHONE Vv <br /> ........................................................................................... . ................................................................. .... <br /> PLUMBER WELL DRILLER TL.J <br /> ........................................................................................... .AD......D. ..RES.. ........................................................................... .... O <br /> ADDRESS S <br /> PHONE PHONE Z N r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms c <br /> Now Building Type of Construction: No. Bedrooms ..... .... [ <br /> Addition .......... .................................................... Septic Tank Size Gals. ..... .... < <br /> Sanitary .......... Size .............. ft. x .............. ft. ..... .... i i <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Area Soil Type ............................... .... r <br /> .......... ........................................... <br /> Mobile Home Sloe ° <br /> .......... P ..................................... .... <br /> Privy ........-, 3. Use (describe exactly, 1 -family <br /> Perc. Rate .............................. .... <br /> Well 'wx� home,garage, motel,etc.) Y Well �_ <br /> Subdivision `V— Seepage Trench z <br /> ..... .... o <br /> CampingUnit .......... .................................................... Priv ..... .... <br /> Seepage Bed <br /> ..... . .. � <br /> --------------------------------------------------------------------- - <br /> Location of proposed structures and existing structures well sewage systems, roads, etc., should be sketched in Fig. A. �� I c <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is locatet I at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersects n. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. �� 0L--: <br /> J <br /> 5. Lot Size: Fig. A. 6. Location: 2e <br /> ................ ft. x .............. ft. — ............................... sq.ft. ......................................................................... ..... t :J <br /> C�i"C (�I N O <br /> O J <br /> J <br /> VO `c Oj 54-6 <br /> T o <br /> f � <br /> Z Z <br /> O <br /> d <br /> :U1 <br /> F <br /> M W vi rr > W ao � <br /> 95! <br /> L 0 (O m <br /> O HO . D 1 <br /> $(T) Jn : m <br /> ignature of Owner or Agent Date : o <br /> Remarks ..................................................................... "' �• <br /> N . <br /> n <br /> ...................................................................................................................................................................................... ^ P <br /> V O <br /> ............................................................................I.......................... <br /> ... ........... ..� /f .... .. . .......................... . <br /> Inspection Date ....................................... .... .. .. .. . W.. Q .... . N tai, N O O fNi� m <br /> . ... . . . . ... m <br /> Hing Administra 8 $ 0 8 0 8 to <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facil ties before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this applic tion 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 i 5sued. 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 />