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V J77! <br />Burnett County Office of Zoning Administrator0 0 <br />APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT v• 3. 3 <br />o <br />TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as <br />shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m S� <br />Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a '� <br />O <br />'4�......d J�/.4N H m <br />/7,fRBCR...!I.....M°..!...................................... <br />OWNER (please print)7..CONTRACTOR or SURVEYOR or AGENT a <br />STjaR RT/; /JIJk �.3 5 a <br />ADDRESS ADDRESS <br />.:......................................................................................................................................... <br />ADDRESS ADDRESS �. <br />........... <br />....................................................................................... <br />PHONE PH..ONE....� •� <br />................................................................................................................. <br />PLUMBER <br />WELL <br />DRILLER • <br />........................................................................ <br />0 <br />ADDRESS ADDRESS 0 o <br />r+ � <br />................................................................................... o :3 o <br />PHONE PHONE 2 y r <br />DESCRIPTION 4. Sanitary Facilities: rte; o <br />1. Work: No. Bathrooms 0 <br />2. New Building Details ; o <br />No. Bedrooms .......... v <br />New Building .......... Type of Construction: . <br />Addition Septic Tank Size Gals. ..........j; <br />✓..... <br />.............. .... <br />Sanitary .......... ft. <br />.......... Size ...�...... ft. x / <br />Filling/Grading .......... Height ........... Stories ............. 4a. Absorption Field Site: q <br />s Soil Type .................................... m <br />Moving .......... Area ... 3. �.� .q:f."..................... Z o <br />Slope <br />Mobile Home <br />Privy .......... 3. Use (describe exactly, 1 - family Perc. Rate ................................... W <br />Dry Well <br />Well .......... home, gara4e, motel, etc.) """"" v '• <br />Subdivision „•,,,•,,, pp!: / oOK Seepage Trench .......... <br />..Gl....................................I...... Privy <br />Camping Unit <br />Seepage Bed .......... <br />-- — <br />Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road 6 <br />setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- _ Q <br />section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING ZW <br />A <br />STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br />------------------------------ <br />5. Lot Size: Fig. A. 6. Location: <br />leo'X ggA? ft. x .............. ft. — ............................... sq. ft................................................................................ <br />N O' <br />O <br />7 <br />OVER I�%�'f' —I <br />TI <br />oo` 4—CD <br />z <br />CD <br />X cn r- T c m <br />U-' < % <br />�. f1i 9: < to �° <br />a cn < y <br />fCD <br />z CD >a � 70 <br />O a <br />Ln ° "I <br />*o O 7p <br />.....B-zU-py........ o p <br />Signatur4e of Own r Agent Date — <br />Remarks,, ...r .s.7.. n <br />X v <br />................................................................................................................ I • : : : m <br />CD <br />:. <br />....................................................................................................................................................................................... . <br />...................................... + a . . . . . . TI <br />InspectionDate ....................................... C�'hGlo.......:................................................. o o o o m <br />Zoning Admin' trator iC o 0 0 o N <br />0 0 000000 <br />0 0 <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 made without approval of the Zoning Administrator. <br />SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />