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. 2p-7,JG <br /> Burnett County Office of Zoning Administrator c - H 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 * �. <br /> " <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as ' H o J <br /> showC.), <br /> n herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use C c <br /> Ordinance, Sanitation Code,and, <br /> with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a ,� <br /> G � �� Li �t�/S 7-' F ami O <br /> OWN R (please print) CONTRACTOR or SURVEYOR or AGENT o Nt ' <br /> ADDRESS % ADDRESS <br /> 14��+iGSs"itd.-Ef Ohl/-o fff���/// <br /> ADDRESS ADDRESS <br /> PHONE PHONE v • <br /> -41 <br /> PLUMBER WELL DRILLER ``> <br /> O. <br /> ADDRESS ADDRESS <br /> o <br /> o ,-: <br /> PHONE PHONE H r <br /> DESCRIPTION 4. Sanitary Facilities: P o P. <br /> 1. Work: No. Bathrooms Jam+ <br /> 2. New Building Details a <br /> New Building No. Bedrooms o <br /> �(. Type of Construction: CD <br /> Addition rk.. Septic Tank Size Gals. <br /> Sanitary Size .../ .. ft. x .2.0 ft. <br /> Filling/Grading Height../ ,.3ories / 4a. Absorption Field Site: <br /> Moving Area Soil Type , <br /> Mobile Home Slope �` ° <br /> Privy 3. Use (describe exactly, 1 -family <br /> Perc. Rate <br /> Well homgarage, motel,etc.) Dry Well <br /> N. <br /> Subdivision -64 ireSeepage Trench <br /> Camping Unit Privy <br /> Seepage Bed i 6 <br /> Location of proposed structures and existing structures,well, sewage systems, roads,etc., should be sketched in Fig. A. Include road C.) <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located.at a highway inter- <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. G 5' <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ft. x ft. — sq.ft. <br /> cn <br /> CD <br /> 0 <br /> N o <br /> o <br /> 7 <br /> 5. R1 <br /> JX' ''1 0 <br /> rnUj h o <br /> N <br /> N , <br /> r,.... T .1. <br /> CD f' <br /> z <br /> 0 <br /> DO <br /> CO <br /> CD <br /> C/! r <br /> l /Piat Li 42 M M4 g4 u"� <br /> arecd �iV�e aid - z < C d <br /> fi . Ora t v� F , <br /> /yy� -o t0 z „, - r'c <br /> 40 ke)f r 14 -(')( betdrn� 1., v I L c1 i v, U4 i U (VI v l 7� 0 � p <br /> — <br /> C <br /> 6:14)VSignature of Owner or Agent �4'y Date o — <br /> X 77 <br /> Remarks <br /> CD 0 <br /> CD <br /> En _ <br /> v' 1 N 8 OD N <br /> Inspection Date2YZb,/9 <br /> a 0 0 0 0 0 .o <br /> Zoning Adm42satoo 0 0 0 0 0 <br /> DOTE: 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 /> vith 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 />