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i.✓ftL G'7l/-' <br /> Burnett County Office of Zoning Administrator 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as rn <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m 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 /> -� I �1 II - // n 0 <br /> A <br /> r.q........ :.....iJa.t .�..d..N.......... ............................................................................................ <br /> OWNER (please CONTRACTOR or SURVEYOR or AGENT o. <br /> at.'j �....... . .rroC`' .e..V...l.e. ......J- N� <br /> d ... ........ . ................................................................................. d <br /> ADDRESS ADDRESS <br /> m <br /> N <br /> rr{a.u.7..�]... I ' I X11 7 w <br /> A DRE S ADDRESS <br /> PHONE. ............................................................................... PHONE <br /> . . ............................................................................................ <br /> PLUMBER WELL DRILLER <br /> ................................................................................I.......... ............................................................................................ � V <br /> ADDRESS ADDRESS m G) <br /> Et <br /> ........................................................................................... ................................................... ....................................... o o• <br /> PHONE PHONE Z r <br /> DESCRIPTION 4. SanitaryFacilities: 0 8 0 <br /> i. Work: No. Bathrooms <br /> 2. New Building Details """"" (, o :(A <br /> a <br /> New Building .,,,,...,, Type of Construction: No. Bedrooms """"" m <br /> Addition ................................. ............... Septic Tank Size Gals. ........,. <br /> .�... .... aa <br /> ... \j'• i i <br /> Sanitary ,,,,,,,,,, Site ..... .�.... ft. x .J.d...... ft. ....... <br /> Filling/Grading .......... Height....K...... Stories .../......... 4a. Absorption Field Site: i <br /> rilType .................................... E <br /> Moving .......... Area ............................... ........... So � o <br /> Mobile Home . .... Slope .......................................... .. <br /> .... . <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Well .......... home,garage, motel, etc.) Dry Well .......... <br /> --`. ..... a- IY/ ..........subdivision ...,.,,,,, dml1.... - dlJSeepage Trench <br /> Privy <br /> ..........Camping Unit .......... 1YR7Seepage Bed <br /> ......... <br /> Location of proposed structures and existing structures,well,sewage systems, roads, etc., should be sketched in Fig A. Include road :M <br /> setback, side and back yard dimension and location and setback from all bodies of water If property is located at a highway inter <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING f �N'iJ <br /> O <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. O� <br /> ------------------------------------------------------ <br /> $a C 5. Lot Lot Size: , / Fig. A. 6 Location: to <br /> ../..l2..�..... ft. x .y.L...o ft. — ............................... sq. ft. .. .1 ...°�..4.V.V.3,'7 3 a See, 13 �... _' <br /> i..0 .3 Y � c7 77 ..w �o-w La-L 3 � rn. <br /> /L,11 SAC a o <br /> rd 0 <br /> Z <br /> O <br /> d <br /> zy" <br /> I <br /> < m Z <br /> � NO- QJ <br /> Z o0 <br /> on <br /> to 3 <br /> 1 <br /> o <br /> y...-.� - 5. W o <br /> Signature of Ow er A ent Date — <br /> X <br /> Remarks m <br /> al <br /> v <br /> err <br /> .......................................................................................................................................................................... <br /> ' <br /> c : <br /> ....................................................................................................... .. ............................ ..... ....................................... m <br /> �� � T' ............. ' gyp` I'n r�i. oU ouHNiT <br /> InspectionDate ....................................... . . ....................... .............. . ..... ......... <br /> ZoningAdm' istrator T j 8 8 8 8 8 8 N <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <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 />