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Burne;t County Office of Zoning Administfor LA c <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 °� <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements f the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the law and 3 <br /> regulations of the State of Wisconsin. » n 7 (1 <br /> Syo�zEL/ VE SERV/C.�.. R CtUNS .. m J <br /> OWNER (please print) C SURVEYOR or AGENT <br /> I...'. ' .. ..... ..Y............ ............................................................... ........ d p <br /> � � 41.1 <br /> ADDR.`ESS ADORE 1 <br /> dx7 <br /> ADDRESS ADDRESS 112. !�� <br /> `3 y z L� 4- <br /> PHONE ............ ............:..... . r6.. �... <br /> T....................... ................................... . <br /> .............................................................. PHONE ( i <br /> . . . ..................... .. .................................................... ........ [v <br /> PLUMBER WELL DRILLE <br /> O <br /> ADDRESS ADDRESS C <br /> n <br /> ........................................... ........ O <br /> ........................................................................................... .P..H..ONE................................... <br /> PHONE N <br /> Z <br /> DESCRIPTION 4. Sanitary Facilities: 8 <br /> No. Bathrooms <br /> i. Work: 2. New BuildingDetails <br /> T Uof//LC,,o ructi t— <br /> No. Bedrooms <br /> N """"'New Building <br /> AdditionSeptic Tank Size Gals. ...... <br /> .......... <br /> Sanitary .......... <br /> - <br /> FillingfGroding .......... Height.../..2.r.. Stories ............... 4a. Absorption Field Site: <br /> Moving Area ..........:Z...�...:?............... Soil TYPe ................. ..... ......... o <br /> .......... <br /> Slope ........... <br /> Mobile Home ,,,,...... �• ••••• <br /> Privy .......... 3. Use (describe exactly,'1 -family Perc. Rate .......... .... . .... ......... 0 0k <br /> Well ,......... home,garage, motel, etc.) Dry Well ......... Z <br /> Subdivision .......... rj,,� — Seepage Trench ......... <br /> .. ........ x.� .............. Privy <br /> g ......... - <br /> Camping unit .......... ................................................... Seepage Bed <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in ig. A. ;J F <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. 0 <br /> ------------------------------ <br /> 5. Lot Size: Fig. A. 6. Location:�/�`G 7 <br /> ................ ft. x -........... ft. — ..l�� .�rJsQ.ft. .............6/.. �'� J <br /> U7 <br /> N � O <br /> o J <br /> J <br /> Z :0 <br /> O <br /> N <br /> J <br /> u] <br /> m <br /> mC N N 00 <br /> rn <br /> m N n m m EL a y <br /> G d C y J J <br /> Z <br /> 0 <br /> OO : N D� <br /> O A J n n <br /> " 0 : O <br /> V ....... .. ............................................. ...................................... : p <br /> Signature of Own r Agent / ate $ <br /> Remarks ' .� .M i� Sf��� �ti Ute`-c(s�'�"' ll�/Y'✓C' /'✓ <br /> ........ . lel.............../..:.............C...................�f.. ��.�G.................... ....... <br /> �2 / WX.................................... j o <br /> ................ . .. r. . .. .....T. . <br /> .................... . ......................................................................... ; <br /> g o <br /> Inspection Date //�/[�,JG��.�—�"-- N m N N <br /> Zoning Administrator o g g o g <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary acilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this ap Aication 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 en issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans 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 AND APPROVED. <br />