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Burnett County Office of Zoning Administratoru Z <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT »' 3 :Dic <br /> d w J <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as <br /> 57 <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 /> v � . <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 0. <br /> E) <br /> ✓�pms............ T..ok�s <br /> OW/N�ER (please print) CONTRACTOR or SURVEYOR or AGENT m m <br /> ADDRESS <br /> ..°'.^.T.............................................................................. . .ADDRES. .. . . .S. ......... ....................................................... ............. a <br /> F <br /> AID,rDJ.Ep.sT.Z:-?... .... C/f.s.........16-r.Y9- ............... ............................................................................................ <br /> SS <br /> ADDRESS <br /> ....................................... .......... . <br /> .... <br /> ..................................... . .......................................................................................... <br /> PHONE PHONE <br /> .... ..0 jill..........XCle. v ................ ... .PLUMBER .. .. ............................................................................................ <br /> WELL DRILLER ; <br /> . ESr,........�......>����... ......s: i ........................................................................................... <br /> ADDRESS .y . <br /> ADDRESS <br /> a o <br /> PHONE ................................................... PHONE................................................................................ j, o <br /> 0 <br /> DESCRIPTION Z <br /> 4. Sanitary Facilities: ° $ o <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details ..... .. � , <br /> New Building Type of Construction: No. Bedrooms ... .. �° <br /> Addition .. Septic Tank Size Gals. d'.G,J <br /> Sanitary ,,,/..... Size .............. ft. x ft. .......... <br /> .es......... � < <br /> Filling/Grading <br /> ....... Height............. Stories ............... 4a. Absorption Field Site: ^ <br /> Moving .......... Area ........................ Soil Type ......... :.�A.l�.A.... ..... r '. <br /> ................... <br /> Mobile Home : o <br /> .......... Slope .......... ... .V....................... _ <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate .................1............... 7; <br /> Well .......... home,garage, motel, .) Dry Well .......... <br /> Subdivision ,,,, t <br /> ,... r.... Seepage Trench .......... <br /> Camping Unit Privy <br /> Seepage Bed <br /> ----------------------------------------------------------- <br /> — f' <br /> — ------ ' <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road t N! <br /> :Cy) <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 5 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. - <br /> -------------------------------------------------- <br /> _________________ / <br /> ____________________________________________ _ <br /> 5. Lot Size: CIN- <br /> 0 <br /> Pe/Z I-oT Fig. A. 6. Location: <br /> ft. x .............. ft. . ............................... sq.ft. <br /> S T/ <br /> m <br /> N p' <br /> o <br /> rT'E� ATTAC.11I 1bZ.9n1 <br /> 0 <br /> o <br /> t 7 <br /> z <br /> Q <br /> 0 <br /> m <br /> m <br /> M N r 13 :E m M Z <br /> n� 64 MlTa'�" a C� � m � v <br /> z 5;. <br /> a > >p <br /> o <br /> `.. .. M <br /> �D <br /> ... ... ... �. 1� <br /> ........................ ...Q.-.a -�y...... o <br /> Si ature o/f O�weer or Agent Date m <br /> X 70 <br /> Remarks <br /> m <br /> ........................................................................................................................................................................................ ss <br /> ........................................................................................................... .................... ....... ............�............................ . . <br /> 8 $Mn Inspection Date ....................................... ON.......... .. y. O <br /> Zoning Admstrator Oo ggg <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary fdcilitics <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 />