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Burnett County Office of Zoning Administre or 2' c <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT - '— <br /> 3. €0) <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described nd <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the ,B <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws nd 3 <br /> regulations of the State of Wisconsin. » a <br /> 0 01 S A 9 <br /> OWNSt.t leas..print) 4.................................. .......:. .......... ......'...1...................{y. . . .............................................. ..... <br /> OWNER (please print) _� CONTRACTOR or S�IRV EVOR or AGENT ; <br /> .. ...1�.../...3.. ............................................................ .......... .......................................................................... ...... <br /> ADDRESS ADDRESS = 1 !� <br /> °..3�............... ..................................................................................... ...... s� <br /> ADDRESS ADDRESS ;3j 1 :1 <br /> .................................................................... <br /> pH PHONE <br /> PLUMBER WELL DRILLER :q <br /> O <br /> ;L' <br /> ........................................... ...... <br /> ......... . ............................................................................... . ...... . ............................ — 4 <br /> ADDRESS AD.. DR..ES..S m u7 <br /> tt <ct <br /> G <br /> ........................................................................................... .P..H..ON....E............................................................................ ...... <br /> PHONE Zr <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> 1. Work: No. Bathrooms '- <br /> 2. New Building Details """"' o i <br /> New Building ,,,✓ Type," No. Bedrooms <br /> "' """ � <br /> J-7^ci.�� SeAdditionptic Tank Size Gals. .... •tet <br /> Sanitary ..5:..... Size ....ay... ft. x .......9..... ft. [ i <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area <br /> y � <br /> Soil Type ............................ ....... <br /> Slope ..........................Mobile Home .......... ........ <br /> I...... v .�. <br /> Privy 3. Use (describe exactly •famil Perc. Rate ........................... ....... ' <br /> ......... <br /> Well .......... home,garage, motel,etc. Ory Well m `• <br /> Subdivision �L. p ,••••,•, Seepage Trench o <br /> I... t3M..... .....F}o. L <br /> pg v <br /> camping Unit .......... .....................�............................ Priv <br /> Seepage Bed <br /> _______________________________ __----------------____— -- � N <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. - 7) <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is local d at Y g <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersec ion. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. 0 <br /> ___________________________________________________________________ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq.ft. ...................................................................... ........ `b C <br /> N O <br /> O J <br /> J <br /> 0 ^ ' <br /> O <br /> j <br /> . O <br /> Z <br /> m Q <br /> Z <br /> O <br /> W <br /> J <br /> b <br /> O• N (n -o <br /> N N O W Cm -0 <br /> O H(1 < J J O -• -• m <br /> 90< dCy ❑ J ; <br /> O N •c O t> <br /> a o m <br /> e�a.. .... .. . ................9................................... ...................................... <br /> Q FIT <br /> Si lure o caner or A ant Date <br /> Remarks .. ....� �6-L.`�—s--_ 0: m <br /> ........................ N <br /> O . C <br /> ........................................................................................................... Aioni'ng <br /> ....... ...... ... .. ............. ..... T <br /> N N - NInspection Date ....1 . �D.�..0.. .. ....... .. ....... ............. .... �'�u,Spun o O <n mAd inistrator �8 8 8 8 8 841 <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this app ication 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 bee i issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or 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 />