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[�. <br /> Burnett County Office of Zoning Administrator iv - 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT2. m. <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as '< v 0 <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m c <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a `a <br /> Cra'4:v /2/46.24-et.) �1.6h-� e. w u, Q <br /> N r-F <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT a CD <br /> ADDRESS ADDRESS , 41/ S«93 mi Sls <br /> ADDRESS ADDRESS tst, <br /> PHONE PHONE <br /> ,t- . <br /> N. <br /> PLUMBER WELL DRILLER <br /> C. <br /> ADDRESS ADDRESS ; G) <br /> no <br /> P+. <br /> r+ <br /> PHONE PHONEZ y • <br /> DESCRIPTION 4. Sanitary Facilities: P o ° <br /> 1. Work: 2. New Building Details No. Bathrooms o <br /> New Building Type of Construction: No. Bedrooms o <br /> Addition Septic Tank Size Gals. <br /> Sanitary Size ft. x ft. <br /> Filling Height Stories 4a. Absorption Field Site: <br /> Moving Area Soil Type r- <br /> Grading Slope ° <br /> Mobile Home 3. Use (describe exactly, 1 -family Perc. Rate a <br /> Privy home,garage, motel, etc.) <br /> Dry Well :g. <br /> Well Seepage Trench <br /> Subdivision ✓ Privy <br /> Seepage Bed <br /> N C <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road c.. N <br /> • <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- o- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. 6' <br /> 6 <br /> 04 <br /> 5. Lot Size: Fig. A. 6. Location: Prl <br /> ft. x ft. — sq.ft. <br /> S.,,,, Qac elC�5/22CD <br /> N O' <br /> o <br /> o <br /> _J T <br /> 1 V. T <br /> tiP ��Il ,- <br /> I I <br /> z <br /> i� R, O <br /> J1, U� 73 <br /> o <br /> N <br /> N. <br /> '. 00 cn 7* cn03Z <br /> d <br /> a 'bOy. < to * m <br /> z oo fD : : m 70 <br /> o o <br /> iso5' 3 <br /> o,01 0 - <br /> u1-,,, m <br /> Signature of Owner or Agent Date r+ <br /> X 70 <br /> Remarks • • m <br /> TA • <br /> II <br /> CA IA <br /> Inspection Date �G2'7ZP0 7g / 1° 0 0 0 0 0 cNn m <br /> ZoningAdministraor IC ) \` o0000ocm/s <br /> IOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> efore 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 /> ig until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> 'ith 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 />