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N COMPUTER/SC�NI ce of Zoning Administrator C <br /> O <br /> Burnett County z <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 '< H o <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land _ <br /> Ordinance, Sanitation <br /> Use-Code, and with all other applicable County Ordinances the la and regulati ns of the State of Wisconsin. CD fD 1 <br /> CL <br /> G..Q.�r 1 ......... <?. r. ...... ° o <br /> .... <br /> OWN lease print) <br /> C RACTOR or SURVEY or AGENT <br /> J.......J1f - 0 /� R z <br /> r r n <br /> m <br /> ADESS .... ...(.. ..................................... <br /> ADDRESS <br /> ADDRE S DDRESS <br /> ADDRESS ...........f.................................................... <br /> .......................... <br /> PHONE ......................................... <br /> PHONE <br /> PLUMBER ................................................................................... <br /> WELL DRILLER ; <br /> ADDRESS .......................................................................................... v :0 <br /> ADDRESS —• <br /> ........................................................................................... " G <br /> PHONE .........................................................................•............... o <br /> PHONE <br /> DESCRIPTION z y <br /> 4. Sanita Facilities: o <br /> 1. Work: - ' o �« <br /> 2. New Building Details No. Bat corn <br /> New Building ... Ty e of Constructio No. Bedro ms <br /> O <br /> Addition k-y-�+e.... ,►r. f ......... Septic Tank Size Gals. <br /> .......... <br /> Sanitary .......... Size f. ..... ft. x .a�`/....., ft " YYS <br /> Filling/Grading Height Stories 4a. Absor ion Field Site: <br /> MovingArea Soil Typ.......................................... .................................... a . m <br /> Mobile Home Slope <br /> 0 <br /> .......... ........•..................•...... <br /> Privy 3. Use (describe exactly, 1 -family Perc. Rate ... . <br /> Well home age motel, etc.) Dry Well <br /> Subdivision Seepage Trench '• <br /> ��! .......... o�J....................... . . : <br /> Camping Unit Privy <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 �` N <br /> setback, side and back Property <br /> y 1 �yard dimension and location and setback from all bodies of water. If ro ert is located at a highwayinter- a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING C) <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. y' <br /> ----------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ft. x .............. ft. — ............................... sq.ft. ............................................................................... <br /> Cn <br /> CD <br /> c <br /> 0 0' <br /> 3 D <br /> _o <br /> F <br /> N <br /> e � CD <br /> 'Id z <br /> CD <br /> v <br /> Z 7[J Cn r S1.0 <br /> oo Z <br /> v CD N Q C <br /> / 3 Ln Z. m W <br /> 1 0 op' � Dam <br /> \/ o 0 a <br /> CL <br /> cn <br /> C�J g <br /> �= � p <br /> ....... <br /> signature of Ow»er or Ag t Date C <br /> emarks ......................................................................................................................................................................... x <br /> -n m <br /> CD <br /> CD <br /> v <br /> ..................................................................................................................................................................................... <br /> ......................................................................................................... :Q: <br /> co M <br /> tspection Date ................................. . ... ator) <br /> ................................ oo m <br /> Zonin dministrator o 0 0 0 o N <br /> )TE: A preliminary site inspection must be made and site approval granted on all structures involving s iitary facilities <br /> fore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> Is application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> ) until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> th is found to exist. Changes in plans or specifications shall not lie made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br /> J <br />