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i �-, <br /> c_� n )r <br /> Burnett County Office of Zoning Administrator H 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT R. b <br /> o ,� <br /> r0 THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as - to <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use CC° <br /> Drdinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> --7,./ " a <br /> o <br /> N ,c4) k <br /> DWNER (please print) CONTRACT R or SURVEY or AGENT C m <br /> 4DDRESS ADDRESS °» <br /> co <br /> 4DDRESS ADDRESS yv <br /> x <br /> 'HONE PHONE <br /> Nk <br /> 'LUMBER WELL DRILLER <br /> 0 <br /> ADDRESS ADDRESS 0 <br /> n 0 <br /> o' ,-,' <br /> 'HONE PHONE Z N 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 co <br /> o <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 7 <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 Seepage Trench <br /> Camping Unit Privy <br /> Seepage Bed <br /> f/) <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 /> Z. <br /> 16ction, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. 6 <br /> o' <br /> c <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ft. x ft. — sq.ft. <br /> S/)? Cl)s — CD <br /> , :11-7 1 j C' \ ';J qj 9,) 5. <br /> co iN, <br /> I rJt 0 <br /> 1 01 <br /> j 0 <br /> I 7 <br /> Vf <br /> u <br /> G t <br /> ,,j , i <br /> z <br /> 73 <br /> (0 <br /> CD <br /> (--; <br /> a M tn * maoz <br /> r "0m <br /> .cry Cr a *m• t") ca• C< w W <br /> 'O-a m C) _. 4-. ON• D n. m <br /> Z 6' <br /> o ' 3 <br /> rfl - <br /> tjA <br /> ‘ 1 0 DO <br /> A)1 <br /> \ CD <br /> Signature of Owner or Agent Date O C— <br /> X XI <br /> Remarks m mm <br /> m <br /> 69 <br /> .t II <br /> } <br /> Inspection Datec7rfiirge <br /> o u o o °n o CT m <br /> Zoning Administrator 1° o 0 o o o o N <br /> IOTE: 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 t&st 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 /> ig until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> dith is found to exist. Changes in plans or specifications shall not be made without approval of the Zoning Adm inistrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />