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�77 6,.Q-7,' . <br /> Burnett County Office of Zoning Administrator 3 - 00 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT g * •N. <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < y -' <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use 2 c • ,p <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a () <br /> a o <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT a <br /> ADDRESS ADDRESS F' '. , <br /> ADDRESS ADDRESS <br /> 'S_ Y4- yfP <br /> PHONE PHONE <br /> NO <br /> t'cl \/J <br /> PLUMBER WELL DRILLER <br /> C3 <br /> ADDRESS ADDRESS G-) <br /> 0 o <br /> h < <br /> 0 ,-' <br /> PHONE PHONE z <br /> DESCRIPTION 0 <br /> 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms �. o <br /> New Building TypeNo. Bedrooms c <br /> of Construction: c <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 1 7 <br /> Mobile Home Slope i <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 S6 <br /> Seepage Bed .k <br /> PA ci) <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road . <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- I o- <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. (4 o• <br /> 5. Lot Size: Fig. A. 6. Location: (, <br /> ft. x ft. — sq.ft. <br /> gl <br /> 10 214-ti-t C a..v,. co 0 0 C-Lf. j' &J k. <br /> R. <br /> N <br /> cra <br /> eie-egA e_4.,c_itZty 3 0 i a":- „6.../.4.z.40._ice-i_e_ el_-.---ti-ylf-e-4-e&-Ay•dtipt ,-. <br /> �- n O o <br /> ,e G ---63-uf �e� -mot -t ,, ,_ --6" ,-..,,,C o-Zi-[-� 0 <br /> S <br /> T <br /> 3.4 <br /> 0 <br /> D3 <br /> v <br /> n <br /> G - ry <br /> f )Li F,/,,no of G ,1 b1 1-Ake ,5ho,�e ,r�.Tt To flc /) *- <br /> v <br /> /Ge RtcJr. . 1 <br /> 6 < _ - <br /> z o5 a ; 70 <br /> o m <br /> afi-t-f //-S v <br /> p <br /> Signature of Owner or Agent Date <br /> o c <br /> Remarks m X 64 <br /> m70 <br /> — <br /> 3 n It <br /> T <br /> 6,9 <br /> Inspection Date CT o al o m <br /> Zoning A inistrator • 0 0 0 0 ,0 N <br /> lOT E: 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 /> its 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 /> 'ith 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 />