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yid C,-7 __vn . <br /> Burnett County Office of Zoning Administrator 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT a 3D <br /> g <br /> TO THE ZONING ADMINISTRATOR. The undersigned herebymakes application for a Permit for the work described and located as < r; <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m mj ;-\u <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. <br /> m O <br /> ......R.o.he.c.t...J.a.c.k....................................................... .....Jamisna...Cnns.t._................................................ C . <br /> f <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT m <br /> ,..,,5008._Humbolt...Ave..,No .,.,.M.p1s...M.inn 55430... <br /> ,..._B,ox...369.-Siren,,W.is54872 <br /> ADDRESS ADDRESS <br /> .............. . <br /> ............................................................................ .ADD........R..ESS................................................................... <br /> ADDRESS <br /> ......NONE...................................... 349,-.562. .................................................................. <br /> ..... r <br /> PHONE PHONE <br /> ......CLQ.e....I�......J.1.W.],.S.O.R............................................... .....J.u.e...M I.... ami.son................................................ y� y ; _._. <br /> PLUMBER WELL DRILLER <br /> B.ox...3.6.9Si.r.en.................................................... .....B.o.x...36.9.-Si.z.e.u................................................... A <br /> ADDRESS ADDRESS n o 1� <br /> ^, C <br /> ......3.4.9-5.6.22...........................................................3.49 .56.2.2............................................................................... o <br /> PHONE PHONE Z - <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms 1 .......... <br /> 2. New Building Details o <br /> New Building .X.XXXX Type of Construction: No. Bedrooms 2 .......... \' <br /> Addition Septic Tank Size Gals. 7.5.0.... r? ' <br /> Sanitary ,X,XXXXX Size ...,29...... ft. x .....36..... ft. <br /> n 4a. Absorption Field Site: d <br /> Filling/Grading .......... Height...8.-.Q.. Stories .....1........ TiE ' E <br /> Moving .......... Area864 ' oi .................................... fl: o <br /> .......................................... <br /> Mobile Home Slope .......................................... <br /> Privy .......... 3. Use (describe exactly, 1 -family <br /> Perc. Rate ................................... A :\ <br /> Well .X.X.X.xx X home,garage, motel, etc.) Dry Well .......... .� <br /> Subdivision . ........ 1....£ami.l.y...c.o.t.ta.g.e..�.:. Seepage Trench .......... W i <br /> Camping UnitPrivy .......... <br /> .......... .. . . . <br /> ....... .... . . ............ Seepage Bed .......... t <br /> -------------- -----------------—------------------- �. <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched In Fig_ A. Include roadEn <br /> setback, side and back yard dimension and location and setback from all bodies of water_ If property Is located at a highway Inter- o- <br /> section, show the intersecting highways and the setbacks required along them and at the inmrsection_ CLEARLY LABEL EXISTING -C. <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS --------------------------------- <br /> . o <br /> j � <br /> W <br /> 5. Lot Size: Fig. A. 6. Location: <br /> 10.5....... ft. x ......2.00. ft. <br /> O <br /> m <br /> N � 0� <br /> s W ii <br /> p °A <br /> SEE ATTACHED SCHEDULE <br /> 0 <br /> F <br /> 0 <br /> `T <br /> n <br /> T <br /> d <br /> m <br /> N r v � m W Z <br /> G . m <br /> a cnnC " <br /> Z S o D n <br /> O pn ro <br /> m <br /> ...... .... .. ....July...1.6.th.,.1.985 <br /> Sign o wner or en Date <br /> 1 T x m <br /> Re r s '. ! .. ......... .... .....y..7..7............................................................................................................ m <br /> m <br /> J; N N 0 + N <br /> T <br /> Inspection Date ....................................... .... ..... . .. . .. u, u, o v. o u m <br /> p Z ning Administrator i : 8 0 0 8 8 to <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 m:rrle without approval of the Zoning Administratol . <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />