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Burnett County Office of Zoning Administrator c - H 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMITN_ <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as H <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use co C <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. a j <br /> hh ALE `` a C. <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT Co <br /> m <br /> r ( a_ :` -, <br /> 3 3 `{ � T o iAd .$.O.N S..T.:..Ati. Q . 0. <br /> ADDRESS /� ADDRESS m s-.> O V <br /> fri / 8 /'l A/ . S':.5_`�1 8 — <br /> ADDRES ^� �j u ADDRESS ni C <br /> (SDI �.� fg l - l3i <br /> PHO E PHONE �' <br /> PLUMBER WELL DRILLER r <br /> 0 ;S <br /> ADDRESS ADDRESS o <br /> or.' <br /> PHONE PHONE • <br /> r`v z N r <br /> DESCRIPTION <br /> 4. Sanitary Facilities: . o ° <br /> 1. Work: No. Bathrooms <br /> V 2. New Building Details <br /> New Building v Type of Construction: No. Bedrooms o <br /> Addition Septic Tank Size Gals. <br /> Sanitary Size ..../iha ft. x 2 d ft. <br /> Filling Height /a Stories / 4a. Absorption Field Site: r <br /> Moving Area 3.?:-.0 57, A7', Soil Type SQ" o <br /> Grading Slope i <br /> Mobile Home 3. Use (describe exactly, 1 -family Perc. Rate <br /> Nk <br /> Privy home,garage, motel, etc.) Dry Well g <br /> Well Seepage Trench <br /> Subdivision6.6.4‹. Privy <br /> Seepage Bed i <br /> e.. <br /> Location of proposed structures and existing structures,well, sewage systems, roads,etc.,should be sketched in Fig. A. Include roadC <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 /> N <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> 5. Lot Size: f Fig. A. 6. Location: <br /> /0'Q.... ft. x ....l.50 ft. — sq.ft. <br /> rn <br /> co <br /> Stip t, � lc <br /> �� o O' <br /> -- o <br /> coI\\ <br /> 1 i o <br /> �� W a1 0 <br /> N <br /> sr��- <br /> !�1 �pU 5 o <br /> < < i0 <br /> P.-- ,-"'" anco <br /> .C.,:) <br /> y <br /> lA, FEN) ., cn r 7 * co z <br /> co c m <. m d o . <br /> -O of Z. c d 5. v <br /> _:..______ z o o' m : : CD 70 <br /> 0—a.i..4.- <br /> 44 <br /> P k ) v 4--re -R o 4- D _______ m <br /> .. ....-!..=.. .. a ...1.q. :3 s c_ <br /> Signature of Owner or Agent Dat ��+ <br /> � X 73 <br /> Remarks-2r '41—C„Q) �/q Q -n m <br /> CD CD <br /> v <br /> 01. <br /> S \ II <br /> . �„ <br /> Inspection Date i e o 0 0 o cNi, m <br /> Zoning Ad ' istrator o 0 0 o fmi) <br /> VOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary faciliti+.s <br /> aefore 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 /> rvith 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 />