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V <br /> Burnett County Office of Zoning Administrator Cl) - H 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ;v. . <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as �f <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use c • w\ <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. a �_/J U. <br /> 3 o \ <br /> OWNER (please print) CONTRACTOR SURVEYOR or AGENT C co <br /> . -rikrz. rtr I op:-L...g 6 <br /> ADDRESSfiga..,) 6__Lid,,, ADDRESS CD .it'4' <br /> ADDRESS ADDRESS .94.3 <br /> '. <br /> PHONE <br /> (f" C4 ' J �.l 7 PHONE <br /> PLUMBER WELL DRILLER .N <br /> C). <br /> ADDRESS ADDRESS co C) <br /> 0 <br /> o' ,, <br /> PHONE PHONEz H r <br /> •DESCRIPTION 4. Sanitary Facilities: o o ° <br /> 1. Work: 2. New Building Details No. Bathrooms o <br /> New BuildingV. No. Bedrooms o <br /> Type of onstruction: <br /> Addition 11a o P D A f fr a _ Septic Tank Size Gals. zZ <br /> Sanitary Size a�..... ft. x"..4 t/. ft. <br /> Filling Height Stories i 4a. Absorption Field Site: <br /> Moving Area Soil Type r <br /> Grading Slope ° <br /> Mobile Home 3. Use (describe exactly, 1 -family Perc. Rate 6. <br /> Privy home,garage, motel, etc.) Dry Well <br /> Well -.. � Seepage Trench <br /> kA' <br /> Subdivision Privy <br /> Seepage Bed ail <br /> C <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road Ty, 6 <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- a <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. I o. <br /> O C <br /> 5. Lot Size: •r Fig. A. 6. Loca ' n: US <br /> ..:a.4.1? ft. x ..:d . ft. — sq.ft. .... 0"v` ) 1 §r.‘, if --- liti <br /> t a w r4 <br /> CD <br /> N 5' <br /> o 0 <br /> co • <br /> \ <br /> / / <br /> 0 <br /> I o <br /> C <br /> C <br /> -o' <br /> 7 <br /> z <br /> • o <br /> 'J C <br /> co <br /> m <br /> vl <br /> J cnr13* cnoo <br /> CD d <br /> d <br /> .. oy.. � � m <br /> 0 o� . — 71 <br /> • -co 5' g <br /> cn <br /> co <br /> � <br /> (\0 77 <br /> �/ m <br /> / / �.../ J '�o 0 <br /> Signature of Owner or Agent Date <br /> C <br /> X MI <br /> Remarks • m m <br /> CD <br /> CD <br /> k.! u <br /> UN0 <br /> yyGo ° o 0 0 o -en m <br /> -n <br /> 1c7 <br /> Inspection Date \ o 0 0 0 o m <br /> Zoning Adminis ator ,ry o 0 0 0 © vi <br /> JOTE: A preliminary site inspection must be made and site 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 must be attached to <br /> his application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> ng until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> vith 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 />