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Burnett County Office of Zoning Administrator �' ✓ c <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ^' 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and ^ W <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the ,� c Qj <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the State of Wisconsin. a <br /> Eugene••Becicer <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT <br /> C7 <br /> 6.J.5. Sprin w <br /> ADDRESS ADDRESS m t ;m G <br /> .......Hastan�s ..MN.....55.Q3a....................................... `•(a `•(D <br /> ADDRESS ADDRESS :Ul : ;m <br /> R�uaai Xaa 1e a.....61?_-43.7.-.4.3Q3.................. ........... <br /> PHONE PHONE <br /> .......DAxlal.d..D.ara-els................................................... ............................................................................................ ae ? s <br /> PLUMBER WELL DRILLER <br /> ......3i.r.en'...WZ.....54B72............................................... O <br /> ADDRESS ADDRESS C <br /> 0 < <br /> PHO ................................................................. . <br /> NE Z .: <br /> PHONE........................................................................................... v, <br /> DESCRIPTION 4. Sanitary Facilities: °^ o ° <br /> 1. Work: No. Bathrooms Q) <br /> 2. New Building Details """' o E�5 <br /> New Building .......... Type of Construction: No. Bedrooms .......... Qu 2 Ew <br /> Septic Tank Size Gals. <br /> Addition .......... .................................................... Holding tank 2000,. <br /> Sanitary .....X <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area Soil Type .................................... o i <br /> Slope ..........................................Mobile Home K <br /> .......... <br /> d <br /> Privy ,......... 3. Use (describe exactly 1 -family Perc. Rate ................................... S � : <br /> Well .......... home,garage, motel,etc.) Dry Well .......... .4 <br /> Seepage Trench o � `w <br /> Subdivision """"" <br /> Camping Unit .......... .................................................... Privy .......... r? a <br /> Seepage Bed ......... o <br /> Location of proposed structures and existing structures well sewage systems, roads, etc. should be sketched in Fig. A. :Lin c <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at QJ q <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. r rs <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. 0 �Z <br /> ---------------------------------- —________------------------- 3 iE <br /> 5. Lot Size: Fig. A. 6. Location: :� a <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... Z :0 <br /> r <br /> N j. <br /> tA <br /> 'o r, <br /> o < <br /> m <br /> 0 <br /> 0 <br /> � f <br /> See STate approved plan <br /> T 'W <br /> Z <br /> O <br /> D <br /> N �p <br /> m <br /> N -+ <br /> m c m N n cC cm 'fl <br /> v < > > n - - m <br /> m_ Na•< - nm any <br /> O < d C y p J 3 <br /> 8y : > <br /> D � � <br /> o c m <br /> ............................. .................... .............. ..6/2.5/8.7................... r, : m <br /> P Q <br /> Signature of Owner or Agent Date c <br /> Remarks n <br /> N <br /> ............................................................................................................... .. ...... ........................ <br /> T <br /> InspectionDate ....................................... .......... . . . .......9.... ... .. ........ e e m <br /> Zonin Administrates 0 0 o 0 <br /> NOTE: A preliminary site inspection must be made and site approv I 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 application 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 been 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 AND APPROVED. <br />