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C_{y-yyo <br /> Burnett County Office of Zoning Administrator o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. <br /> o O <br /> TO HE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Perth for the work described and located as 7 — 01) <br /> ,Lown herein- The undersigned agrees that al I work shall be done in accordance win) hw requ,rements of the Burnett County Land Use <br /> Ordinance., Sanitation Code,and with all other applicable Coun Ordinances and the Taws and regulations of the State of Wisconsin. 3 a �: <br /> PP n B <br /> 1 .... . .... ...... . H d <br /> ............... <br /> " <br /> OWNER Ipleaseprinq CONTRACTOR or SURVEYOR or AGENT a '° <br /> i.. .�. .......le..r�.. .......o.�f�� qy <br /> ........................................ ............................................................................................ a fff ��• <br /> AD��99RESS ADDRESS <br /> N.y. .a......... .............. S.S.n.3. '................... iv ice• <br /> ADDRE ADDRESS <br /> (V --q,3 <br /> ri........................................................I.............................. .Plaoiv.E................................................................................ <br /> (Cy ............................................................................................ <br /> W :llv <br /> PLUMBER �_I WELL DRILLER S: <br /> ........... <br /> ........................................................................................... 'A[')'DRESS..RF'S,.................................................................. <br /> \ O <br /> ADDRESS ADi on 0 ob <br /> o <br /> ............. o <br /> ........................................................................................... ............................................................................... <br /> PHONE PHONE Z r <br /> DESCRIPTION 4. Sanitary Facilities: I R o 0 <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details <br /> New Building .,�.<.... Type of_Gonstruction: No. Bedrooms <br /> Addition ......... ''�Y� �' Septic Tank Size Gals. .......... -« y <br /> .. ....... .......... ......................,5.............. <br /> Sanitary .3..U.... ft. ` �' � <br /> Size ...a....�.... ft. x ... <br /> Filling .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ................... .... . Soil Type .................................... o <br /> . <br /> Grading ..... <br /> Slope .......................................... :r <br /> ..... <br /> N <br /> Mobile Home ,,........ 3. Use (describe exact) , 1 -fami Pere. Rate ................................._. �. <br /> Privy .......... home,garage, motel,—77F c. Dry Well .......... <br /> Well Seepage Trench .......... <br /> Priv "f1 <br /> Subdivision ,. ... y <br /> ... ..... ....— Seepage Bed <br /> Location of proposed sti i<t irrs and existing surjclio,svo,ll, s<r,,gP systems roads etc , should be sketched In Fig- A- Include road Al <br /> setback, side and back yatcl dimension and location and setback from all bodias of wirer. If property is located at a highway inter- �s a <br /> section, show the interacting highways and the setbacks required along them and at the 'mtorsection- CLEARLY LABEL EXISTING < <br /> 1�. <br /> STRUCTURES AND PROPOSED STHUCTU HES AND ADDITIONS. <br /> --------------- --------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ...... ft. x .............. ft. . ............................... sq.ft. ..................................................... .......... O <br /> a- <br /> 01 N <br /> p <br /> s <br /> z o <br /> ce <br /> 0 V <br /> • r� <br /> I ' O <br /> IC-71E <br /> � T <br /> c, <br /> >*L 1 O <br /> O <br /> � <br /> ) L a Ja'<O1in. 0 <br /> o' Om <br /> m <br /> 0m � <br /> ffl � <br /> o <br /> i Q m <br /> _ ... .. e ...................... ................. ....... ._......... <br /> o [ p <br /> Signat e .1 O}wtJt�r or Aggeent` '� Date — <br /> fYx4 . � C� X I M <br /> Remarks . .... . .. ............ .....ti.'............................................................................................................................ � <br /> Us <br /> ............../.��/.J/..;......................... c.......p................;........................................................................................................- — <br /> ..............L.1��.'.-/lP1.f.�G'-:!f....GFn..,r: .GfG ................................. ..... .............. ,'... . ......................................... E i E E <br /> ,/ or - — — T <br /> Inspection Date -.�F 7.-G. .... ' �y s -�"` ` m <br /> ..... r........ ......... ........ .................................._ m <br /> Zoning Ad inistrator o 0 0 0 0 o y <br /> NOTE: A preliminary site inspection must be made do 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 rnusl be attached to <br /> this application before a permit will be, issued- Do not purchase or install i septic tank, do any plumping or Stalt any build - <br /> ing until a permit has been issued. A permit may be revol<ed if misrep recantation 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 Adm inistrator . <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPCCTED BY THIS OFFICE AND APPROVED. <br /> ti <br />