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e /- ')C-U7-t1Q <br /> Burnett County Office of Zoning Administrator = CD 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT . 3 — <br /> • 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as '•'' <br /> ..t..shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use CCD c —7 <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. a „/� <br /> - r Q "`C <br /> OV Al S— ►, m ,V.fr.. �%� o <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT a <br /> .S/35— a Lt.ee ti k'a /y1,& 1)1A,i Q ` <br /> ADDRESS ADDRESS m+ <br /> c <br /> ADDRESS ADDRESS (! <br /> PI-fONE PHONE `� <br /> ct <br /> 04 <br /> PLUMBER WELL DRILLER --t, <br /> ADDRESS ADDRESS u L) <br /> o .- 9 <br /> PHONE PHONE z N r <br /> DESCRIPTION 4. Sanitary Facilities: P o ° <br /> NI <br /> 1. Work: 2. New Building Details No. Bathrooms o <br /> New Building y No. Bedrooms <br /> T f Construction: aco <br /> Addition f 2 a4 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 +/ff- V/6 p(wrPe,k Slope ' o <br /> Mobile Home 3. Use (describe exactly, 1 -family Perc. Rate <br /> Privy home,garage, motel etc.) Dry Well <br /> Well Hope ,F �rG. . Seepage Trench <br /> Subdivision (1(3u.tlds•� v,-•e Q„s�>•� ` Privy i I <br /> Seepage Bed <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc., should be sketched in Fig. A. Include road 'c:3c <br /> 0 <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 (t <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. 5' <br /> J 0 sit <br /> 5. Lot Size: Fig. A. 6. Location: w” t <br /> ft. x ft. — sq. ft. <br /> f <br /> )1)6 cn <br /> co <br /> . co <br /> N O. <br /> o <br /> le) j{ •6 .a o <br /> v, <br /> o <br /> n"--:\1%. . el DQL.k Actd,1,0-‘ .- <br /> 1c xro <br /> C / — � 3',' I— CD <br /> z <br /> '" fD ' <br /> / PDo <br /> ` -144, - to _ ,./ `" <br /> cu <br /> co <br /> 1 tV cD <br /> C <br /> DJ Cr) r- 7* Ncoz <br /> cam, S 7 C cp C CD <br /> [P, N Q Q< — ,7 0_ <br /> r+ o � H < co * m <br /> co�Ur o 00 ).-- — <br /> VV I ' 1 I . 1 , CD <br /> m <br /> Signature of Owner or Agent Date I) ° C <br /> X XI <br /> Remarks -n m <br /> CD <br /> yT -64 <br /> r' u <br /> dQ <br /> � � � TI <br /> m <br /> Inspection Date •d o000o b b b b b m <br /> Zoning Administrator o o c o v) <br /> COTE: 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 />