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4?r e'� / <br /> Burnett County Office of Zoning Administri for �' c <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT m 3. <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and i() <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements o the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all Cher applicable County Ordinances and the laws and 3 `8 <br /> regu—latipnss of the Stafej°f Wisconsin. fi Q <br /> .....NI.S�. SC?) 1..................................... .... flc�( ..... ....................................... ...... n1J <br /> OW R (Please print) CONTRACTOR or SURVEYOR or A T <br /> ./C^......�u r . :.. on��...Rd�............. ....��l t r.r......... 1`..�.3..................... ...... d <br /> ADDRESS ; 1 ADDRESS ' <br /> m E <br /> J�-U1 150 ' <br /> ...............S.. .. . ............................................................ .A.............S....................................................................... ...... <br /> ADDRESDDRES <br /> ........................................................................................... .P.HOH.0. N..E................................................................................... <br /> PHONE :CkJ <br /> ........................................................................................... . . .LL DRILLER. ...................................................................... �J <br /> PLUMBER WE <br /> v <br /> ADDRESS ADDRESS [ » C <br /> ........................................................................................... .................................................................................... ....... O .i <br /> PHONE PHONE Z <br /> DESCRIPTION 4. Sanitary Facilities: P o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details •• 'o <br /> New Building ... Type of nstr tion: No. Bedrooms .. ....... <br /> Addition yy++�� Septic Tank Size Gals. .. ....... <br /> LJ.......... ... .. <br /> Sanitary ..... Size ft. x ... ft. <br /> Flllingl Grading .......... Height............. Stories ............... 4a. Absorption Field Site: i <br /> Moving Soil Type ............................ ....... <br /> .......... ........................................... r i <br /> o <br /> Mobile Home .......... Slope .................................. ....... .. <br /> Priv Perc. Rate ........................... . m <br /> Y .......... 3. Use (describe -family ...... <br /> Well home, ara e,m tel, etc.) Dry Well .. ....... <br /> Seepage Trench z <br /> Subdivision G� .. ....... O <br /> .......... .......... ..... ................. <br /> Camping Unit .......... Privy .. ....... <br /> .................................................... Seepage Bed <br /> — i N <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Ft( . A. C <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is local d at p <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersect on. } `— <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. !-i : o <br /> ----------------- ----- --------------------__—_____ -- i i <br /> 5. Lot Size: Fig. A. 6. Location: 0 7( <br /> ................ ft. x .............. ft. — sq.ft. <br /> d� <br /> NO <br /> o ��////'') 3 <br /> O :d <br /> V 0 <br /> < N Decd ro P <br /> 1 <br /> 60I <br /> V q <br /> In <br /> LQv� �rfl`C nvmrDmmIn <br /> m. Nnc - a M any <br /> C <br /> c < w c m > > ; <br /> o g0 m •2 D� 1 <br /> u y a <br /> n : y <br /> n n 0 : p <br /> a . ..... ................. -.. - '. .? o <br /> . A <br /> A <br /> Si nature of Owner or Agent Date <br /> 8 : <br /> Remarks 't m <br /> u, <br /> ....................................................................................................... .... .......................... .. ... ....... <br /> ............ .... O <br /> Inspection Date ....................................... ...... ... . . .... .....I.l...... ...... .�. ... ... N 0, Oon m <br /> Zoning Administrtt r � 8 8 8NOTE: A preliminary site inspection must be made and site appro al granted on all structures involving sanitary fa ilities before constru <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this appli 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 beer 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 APF ROVED. <br />