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Burnett County Office of Zoning Administi ator 19 e <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3• <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work describe and 0 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the 51.E <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the law and n <br /> regulations of the State of WisconJgi n. _ <br /> S ��. "I �vS 0 B p <br /> .....NER Pie seprint)........:.............../�............N..................... ................................................................................... ........ � �� <br /> OWNER Iplaese print) CONTRACTOR or SURVEYOR or AGENT <br /> k` .. . /..1. ..C.............................................. ................................................................................... ........ a <br /> ADDRES ADDRESS <br /> ......... . <br /> ( .G?�VaL.N: ...... ....................... . . . ............................................................................ ........ <br /> ADDRESS ti- ADDRESS i3 <br /> ........... ...�.. ....`.-.�..C�..�... ................................. .................................................................................. ......... : .t <br /> PHONE PHONE ^' <br /> .. . ...... ............................................................................... .................................................................................. ......... <br /> PLUMBER WELL DRILLER <br /> O <br /> ADDRESS AODR ESS n C <br /> ........................................................................................... . . ........................................................................ ......... O 't <br /> PNONE PHONE...... .. Z r <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> y <br /> 1. Work: 2. New Building Details No. Bathrooms ......... e <br /> New Building .,, Type nstruction: No. Bedrooms ......... <br /> Addition ,�,,,,,,,, Septic Tank Size Gals. ......... <br /> Sanitary Size ......b..... ft. x .....�.... ft. •......•• <br /> FillingtGrading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........n0. Soil Type .......................... ......... <br /> .. o <br /> MODIIe Home .......... $IOPe ................................ ......... .. <br /> Privy .......... 3. Use (describe exactly,'1 -family Perc. Rate ......................... ......... <br /> Well .......... home,garage, motel,etc.) Dry Well ......... E <br /> Seepage Trench o <br /> SubdivisiCamping U .......... .......... . .. .. r..�..�.-.... . Privy - <br /> � f Iiia <br /> Camping Unit .......... ........'..1.f.1.`�....... <br /> .................... Seepage Bed <br /> __________________________________________________________________ ___ I i .y <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in ig. A. c <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is loc ted at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the interse tion. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. - o <br /> ----------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: {� <br /> ................ ft. x .............. ft. . ............................... sq. ft. .................................................................... .......... <br /> IS— <br /> IN O <br /> o <br /> Sem <br /> N f <br /> : m <br /> 011 <br /> N <br /> Z <br /> O <br /> A <br /> a <br /> e <br /> m <br /> D Nv (nr DtP ID � <br /> m <br /> Z. <br /> Z So 0 �2 D 1 <br /> o 2 m <br /> o0 <br /> 4. �A <br /> 0 <br /> Jmar,k( <br /> 01K M <br /> of Owner or Agent Dates m a <br /> N <br /> O : S <br /> Inspection Date ....................................... ........ .211:'.J.�../.:......'.f'.C(. � �; L�.. N NOc�_n <br /> mZoning Administr �O rnNOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary cilities before constru <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this ap flication 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 be an issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans c r specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE ANDA PROVED. <br />