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Burnett County Office of Zoning Administrator V c c <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3 <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as H .0 <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use �\ <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. <br /> n <br /> m <br /> ......... ... ........ <br /> ..................... ............................................................................................ c m <br /> OWNER please print) CONTRACTOR or SURVEYOR or AGENT a <br /> /... Q....... ��..��..�11.�..................... <br /> ......................................................................................... d <br /> AARESS ADDRESSi'10 <br /> J .!Y1. .1. .. ...li.:l. l.....7� Q6p.. .............. . .. ................................................................... <br /> AD.0RESS / Q / Q ADDRESS <br /> �!. ..:'....Cl. ✓...-../. .f/... . .... ........... � ....... /� / yO 4q4 . �.................PPHONE <br /> •.p :� <br /> HO <br /> .LUMI. .I ............................................ . . ..................................................................................... ,y <br /> PLUMBERsWELL DRILLER \ ;� <br /> ............... <br /> ........ .. ............................................................. <br /> v <br /> ADDRESS ADDR..ESS.... C) <br /> ti O 1�1 <br /> ........................................................................................... . ............................................ ....................................... o .: <br /> PHONE PHO......NE Z <br /> r <br /> DESCRIPTION 4. SanitaryFacilities: f3 ° o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details y o <br /> New Building .......... Type of oyes ruction: No. Bedrooms .......... F ;� <br /> Addition Z( ........... .................... Septic Tank Size Gals. ...I...... <br /> Sanitary .�.(1............. <br /> ...X..., Size ....Z..a:.... ft. x .............. ft. n •;�J <br /> Filling/Grading Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ......... Soil Type ............................. . . .o <br /> ........................... ...... <br /> Mobile Home .......... Slope .......................................... W ;k9 .. <br /> Privy .......... 3. Use (describe exactly 1 -fami Perc. Rate ...........................:...... <br /> Well ..,,,.,,,, - home,garage, motel, etc. Dry Well e..XisTisq ,..�V... <br /> subdivisiondiv- • .9QGlt— Seepage Trench O .......... w '• <br /> Camping Unit Privy .......... :p <br /> Seepage Bed .......... o <br /> Location of proposed structures and existing structures,well, sewage systems, roads,etc., should be sketched in Fig. A. Include road � h <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter (AJ a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING o .4 <br /> H a <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. y o <br /> ------------------------- - --------------------- — <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... <br /> m <br /> n <br /> Q N O <br /> o <br /> o LQ <br /> �1 0 <br /> Alar <br /> Z <br /> t.x <br /> J <br /> _. <br /> on M Z <br /> Ve Q. a m c m <br /> 7,�C dT VT6 A116(A) Ch < o : m <br /> M // p a: m . D a m <br /> J� t/-(/ o -D n <br /> .Wo <br /> ..T..... .. ....................... .......7..-......—PG........... ET D C <br /> Signat f O ,,., �p „mate CRemarks .C.....!:'....�'.,, `..it'fr�-. �..'�i :V... 1�7'� �' x v <br /> m : <br /> ........................................................................................................... ... ........................... ........................................... . . . . <br /> Inspection Date ..7....x.......56......... ALM m <br /> .. .... ....... ..... . . <br /> ........... °: U8o8o � m <br /> ZoningAdmiry trator 8 8 8 8 8 8 0 <br /> NOTE: A preliminary site inspection must be made d 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 />