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X <br /> ,./ 77. ice► <br /> Burnett County Office of Zoning Administrator ? CD 0o <br /> 0PPLICATION FOR SANITARY — LAND USE — BUILDING PERMITc. 3. a <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as ,n -+' <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. g a \ <br /> f7‘e/V Z.Z(4-)z) I/9" './4 4 /g. etalel...) ir a *v <br /> OWNER (please print) CON TR"TOR or SURVEYOR or AGENT a gi <br /> a • <br /> ADDRESS ADD E,�S��S�� //-- '' 0 <br /> ADDRESS ADDRESS ..'`% <br /> NO <br /> PHONE PHONE <br /> PLUMBER WELL DRILLER <br /> v <br /> ADDRESS ADDRESS CD G) <br /> ,-i.. < <br /> 5 ,- <br /> PHONE PHONEz y r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms o <br /> New Building Type of Construction: No. Bedrooms ^��. cs 3(-1 <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 r <br /> Mobile Home Slope o <br /> Privy 3. Use (describe exactly, 1 -family Perc. Rate <br /> Well home,garage,motel, etc.) Dry Well <br /> Subdivision i/ Seepage Trench <br /> Camping Unit Privy <br /> Seepage Bed <br /> Location of proposed structures and existing structures,well, sewage systems, roads,etc., should be sketched in Fig. A. Include roadW . <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. H <br /> ' <br /> o <br /> 5. Lot Size: Fig. A. 6. Location: -...1.. <br /> ft. x ft. — sq.ft. <br /> '. _ SA,-)tr) , cy <br /> I a <br /> ,. N ) p' <br /> / r-'4.--. D .7 D <br /> Ci . 1JJ <br /> X. iii <br /> i � 01 h ,� o <br /> 1 I 'is <br /> n I tN <br /> J c .-_-_, 2 <br /> i 111 27 <br /> (-. „ ^C <br /> -, o <br /> Z <br /> 0 <br /> p <br /> MI <br /> C., r, Up <br /> 4. <br /> r.--1 <br /> �' <br /> x 'N r- o 5 COw Z <br /> cp <br /> 6a a < fD E. F <br /> -O cn G y `<< um - <br /> Z o o . > a m <br /> o n am <br /> ifl - _ <br /> 10 = •' —I <br /> X) <br /> m <br /> z 7-Py . o C <br /> Signature of Owner or Agent Date h — <br /> X X) <br /> Remarks - R1 m <br /> CD <br /> tfl _ <br /> (,i n <br /> CA NA <br /> T <br /> /� h <br /> Inspection Date 4 ,O .(o/ ' 4 ) /� ° 1g o 0 o 0 o 0 m <br /> Zoning Administrator 0 0 0 00 0 <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 /> Nith 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 />