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77 tom?. <br /> • <br /> 4 1Office of Zoning Administrator v 0 0 <br /> Burnett County 9 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> o <br /> TO THE ZbNING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as ti <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use cow c <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. ] a <br /> ,-r <br /> Mole. 2 /91S0 ' -' - -Er- <br /> 0 0 <br /> v, r•F <br /> F 7 <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENTa Z <br /> / & 7 5R./4 )i,- ig()e- c%) <br /> ADDRES ADDRESS <br /> ADDRESS -5.569ADDRESS <br /> PHONE PHONE <br /> PLUMBER WELL DRILLER ,.-"C r--- <br /> 0 <br /> ADDRESS ADDRESS km C <br /> < c <br /> o <br /> PHONE PHONE zo • <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms • <br /> O <br /> X 2. New Building Details L. <br /> New Building Type of Construction: No. Bedrooms Ch -PD „•t.. <br /> Addition Septic Tank Size Gals. �` <br /> Sanitary x... Size ft. x ft. <br /> Filling Height Stories 4a. Absorption Field Site: <br /> Moving Area Soil Type o <br /> Grading Slope <br /> Perc. Rate <br /> Mobile Home 3. Use (describe exactly, 1 -family DryWell � �� <br /> Privy ho�,e, arage, motel, etc.) N <br /> Well . ,h1..,Ab<n, , / Fit",,� Seepage Trench '��‘ <br /> Subdivision /1.C�K"'-t Privy 1,3 <br /> Seepage Bed i <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc., should be sketched in Fig. A. Include road V1 ' <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- i a 1 <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING a N• <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. W o. <br /> o n// (4 <br /> 5. Lot Size: Fig. A. 6. Location: 0 (.� <br /> ft. x ft. — sq.ft. /(1 <br /> S ;; <br /> U A CD0 <br /> ;fie `7(a-c cJvv�.h"�, <br /> N Z O' <br /> O 7 <br /> 0 44' n <br /> 5' <br /> L <br /> NI <br /> 0--I <br /> N <br /> 5' <br /> r ,r), ,,, <br /> ., <br /> 0 <br /> . <br /> 0 <br /> CD <br /> N, <br /> t <br /> Do N r 7 N W <br /> z <br /> NQa .zE <br /> 1D, < ' Q <br /> -o cn < C m 5' 0 -D <br /> ON fn < c m <br /> Z oo C, : : a <br /> o = <br /> 01 <br /> 0 _ <br /> o Xi <br /> 24104" ))40 -4 - 13 <br /> Signature of Owner or Agent �/ Date <br /> — <br /> x 70 <br /> Remarks (� 1 . CD <br /> Q -T' m <br /> cippi-e <br /> occA <br /> (i v Qom. II <br /> cF ko tdt,c0 TA-'- — o fil <br /> Inspection Date <br /> �° '‘° 0 <br /> ° 000rN0 <br /> Zonin dministrator 0 0 0 0 0 <br /> NOTE: A preliminary site inspection must he made and site approval granted on all structures involving sanitary fa•i itie <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 he made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />