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f/ eit 60791/1 <br /> Burnett County Office of Zoning Administrator 3 0 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT �' g. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < u, <br /> shown herein. The unde7+. a • . <br /> e.,.K;,-„,,,,,z,rsigned agrees that ail work shall be done in accordance with the requirements of the Burnett County Land Use m c —3 <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 o. �,� <br /> yai <br /> 50,,,,idos. <br /> ...Yeryfru. <br /> OWNER (please print) CONTRACTOR or SURyEYOR or AGENT n v cm <br /> ADDRESS ADDRESS j m <br /> V <br /> ADDRESS ADDRESS ClIt- <br /> ikA <br /> PHONE PHONE iti <br /> PLUMBER WELL DRILLER <br /> 0 <br /> ADDRESS ADDRESS m C) 1 <br /> o <br /> o' ?t <br /> PHONE PHONE <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> 1. Work: 2. New Building Details • No. Bathrooms o { <br /> New Building Type of Construction: No. Bedrooms CD <br /> "` <br /> • <br /> Addition Septic Tank Size Gals. • <br /> Sanitary Size ft. x ft. <br /> Filling/Grading Height Stories 4a. Absorption Field Site: <br /> Moving Area Soil Type 1— <br /> o <br /> Mobile Home Slope <br /> Privy 3. Use (describe exactly, 1 -family Perc. Rate <br /> Well home,garage,motel, etc.) Dry Well <br /> Subdivision v Seepage Trench <br /> Camping Unit Privy <br /> Seepage Bed <br /> en . <br /> Location of proposed structures and existing structures,well, sewage systems, roads,etc.,should be sketched in Fig. A. Include road c <br /> o- <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 /> Z. <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> : <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> 5 <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ft. x ft. — sq.ft. <br /> co <br /> 1 N o' <br /> E <br /> 0 0 <br /> y <br /> G o <br /> . 0 <br /> fi <br /> N <br /> Q C 1 <br /> i I a) . . <br /> z <br /> C' c ° D <br /> ,---\ 5) <br /> um <br /> N <br /> tr <br /> -i <br /> rb9 a m - a f <br /> -i '. <' m , -0 <br /> tim > a m <br /> o = a 5 AO <br /> 3 <br /> 01 <br /> scs m <br /> 7-3-iY Q <br /> � <br /> Signature of Owner or Agent Date o <br /> • x 33 <br /> Remarks ,,A 0 <br /> to <br /> O it\- <br /> . mfaq <br /> Inspection Date �o o 0 0 9' mZoning Administrator PQo o o o o o N <br /> VOTE: 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 /> :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 /> 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 />