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Burnett County Office of Zoning Administrator d o 0 <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 located as m <br /> shown herein. The undersigned agrees that all work shall become in accordance with the requirements of the Burnett County Land Usevt <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a i� <br /> . . c.... ...l...K.:»1.: ..�t..r........... .. .. . ... ... T'0'R ....................................... ............ c m <br /> OWNE (please print) / CO. .N.TR.ACTOor SUf�EVOR or AGENT m <br /> ADD :..I...................................... .... .. .......... .ADDRESS............................................................................ <br /> SS <br /> ......2. .............. 1./... <br /> ADDRESS ADDRESS ' <br /> ....................................................................y..... ...-3.. <br /> PHONE PHONE KA <br /> .. . ..-..... . <br /> .............. ............................................................................... . ... .... <br /> PLUMBER WELL DRILLER ' <br /> ........................................................... /. <br /> ADDREss ................... . .......................... /Y?.................................................._... o <br /> ADDREss ry <br /> 0 0 o <br /> PHONE PHONE <br /> DESCRIPTION 4. Sanitary Facilities: <br /> 1. Work: 2. New Building Details No. Bathrooms .......... r': <br /> o <br /> New BuildingNo. Bedrooms .......... L <br /> ...... ... Type of Construction: <br /> Addition ...................... Septic Tank Size Gals. .......... <br /> ... ... ... .......................... <br /> Sanitary .......... Size .... .:�.. ft. x ...r.Z.y.. ft. .......... ,< <br /> Filling/Grading ,,,,,,,,,, Height............. Stories ..uZ......... 4a. Absorption Field Site: - <br /> Moving .......... Area ...`j...7( ...... ?It. Soil Type .................................... � f o <br /> Mobile Home .......... L. Slope .......................................... � [ .. <br /> Privy .......... 3. e. (describe exactly-family Perc. Rate ............... <br /> Well �io�me� arage, m tel, et .) Dry Well .......... <br /> .......... ' pP <br /> Subdivision ,,,,,,,,,, ,u,(/ Seepage Trench .......... <br /> Camping Unit .......... f Privy .......... <br /> .................................................... Seepage Bed <br /> ........ H c i :(A <br /> ----------------------- <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig. A. Include road .� <br /> Q <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway Inter- �� 4 <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLFARLY LABEL EXISTING <br /> o <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o' .r^ <br /> _________________________________________________________________--------- ' <br /> Fig. A. 6. Location <br /> 5. Lot Size: JS ixti - : _ SC�_eZ� <br /> ................ ft. x .............. ft. — ............................... sq. ft. yd 1, <br /> .... r`1•. .SF`S,.r.................i...� - <br /> ................ <br /> } N o <br /> .I <br /> se <br /> I <br /> ��J� 0 <br /> I c� <br /> y� <br /> c <br /> 0 <br /> PliI <br /> L � X <br /> y <br /> tf/U <br /> III M N r V � .N m Z <br /> lid <br /> oori a C : cm TJ <br /> Z 00 0 D o T <br /> o <br /> m 1 <br /> � m <br /> ....C ..1... -C:2I.G:`L.�LJ�.... . ...... .. ...... ........../. .�..` {/. o : p <br /> Signature of QWner d"r Agent ( Datre 00o _ <br /> / x <br /> Remarks ......................................................................................................................................................................... C) <br /> i <br /> ........................................................................................................................................................................................ �°— <br /> � u <br /> ........................................................................................................... Q: <br /> Inspection Date ....................................... ' o o o m <br /> G: <br /> Zoning Adm strator �i o 0 0 0 0 o y <br /> NOTE: A preliminary site inspection must be made and site approval granted on all stinclutes involving sanitary faclli es <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolztion test most be attached to <br /> this application before a permit will be issued. Do not purchase or install a septic tank, do any plumhmg or stat t any bulld <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 />