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Burnett.County Office of Zoning Administrator o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT �• <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 <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws nd 3 pl ate. <br /> regulljtionsof the State of Wisconsin. a n <br /> ..V1. <br /> . .....! !4!.5. .! ................................ . <br /> ................................................................. .... n <br /> OWNppER Iple.� .°f� mtl \ CONTRACTOR or SURVEYOR or AGENT <br /> Itae/A ..!7.. r.. .....CtA!..r.................................. ..................................................................................... ...... <br /> ADDRESS ADDRESS ^ <br /> .. ............................................... ..................................................................................... ...... <br /> ADDRESS <br /> : 1 ? <br /> ADDRESS <br /> .4. h � .1. .....i.�l. ...... .0.4.......... ..................................................................................... ...... <br /> PHONE �•- ..................... PHONE •L <br /> .. j.............................. .n./1..� 1.. ........ ...... <br /> PLUMBER WELL DRILLER r. <br /> ADDRESS ADDRESS o :N <br /> . ....................................................................................... . .............. ..... <br /> ...................... ................................... ...... Z VO,' <br /> PHONE PHON........E <br /> DESCRIPTION 4. Sanitary Facilities: o e o <br /> 1. Work: 2. New Building No. Bathrooms <br /> Details c E <br /> New Building .......... Type of Constr'ispr : No. Bedrooms .. .... R p <br /> Addition / Septic Tank Size Gals. .. <br /> 5_.aCZ.J.../..R.. ................ 'o' 2 <br /> Sanitary Size .............. ft. x ............. ft. -{ i. i <br /> Fiiiingl Grading ,., ,., Height............. Stories ............... 4a. Absorption Field Site. :� <br /> Moving .......... Area Soil Type ............................ ....... r <br /> ........................................ <br /> Mobile Home Slope .................................. ....... <br /> .......... m <br /> Privy .......... 3. Use (describe exactly 1 -famil Perc. Rate ........................... ....... i <br /> m <br /> Well ,,........ home,garage, motel,etc. Dry Well .. ....... _ 0 <br /> Seepage Trench .. ....... o q!1 <br /> Subdivision .......... .................................................... •�'"C➢ <br /> Camping Unit .......... .................................................... Privy 9 o f <br /> Seepa a Bed a. - <br /> ----------------------------------------------------------- -- rn c <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fill. A. S. <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is local d at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersec ion. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. _ o <br /> J <br /> 5. Lot Size: Fig. A. 6. Location: �1 <br /> ................ ft. x .............. ft. . ............................... sq.ft. ...................................................................... ........ x.- <br /> .4 <br /> N O <br /> O J <br /> n 1 <br /> O <br /> A o <br /> I m <br /> 0 i <br /> O <br /> _ J <br /> b <br /> m <br /> :f\h) <br /> D .W M rn r D W co -0 <br /> dC0JJ ; <br /> D - 1 <br /> o c m <br /> O <br /> o <br /> ... 4W�-r-:—r44e--n--t <br /> ................ ....... '6a"t'..Date <br /> Remarks ✓L.j.....C.''2.`:.•a..`.................................................................................................................... ..... i. <br /> ryry////.'.... .. ....... i.1.L. ...................... . ........ .............................................. o : o <br /> ....................... . ............. .. <br /> Inspection Date�.GL.. ..... .. ......... `.{'2,L . /..c,•!d!I:LCt-. .r�f.-L Us.. ....... ..... P m <br /> J T. of N� . . <br /> Zoning Admi strator- Y� <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary f ilities 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 bee i 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 />