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3urnett County Office of Zoning Administrator cn co -9 o 0 <br /> co• APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT . <br /> * •• 3 • <br /> 0 <br /> -O THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as H - <br /> hown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m 0, <br /> )rdinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 �a <br /> //e.e6t) .57,6,#,, 71/4d.„,....e ,,,,h..,,,,, <br /> N h 0 <br /> cp <br /> )WNER (please print) C;bCTO$grSURVEYOR or AGENT a {� <br /> 11,6(((f/ a \ <br /> -: <br /> \DDRESS AD RESS V <br /> �i/ , �i ,)-yff93 <br /> \DDRESS ADDRESS x', <br /> 'HONE PHONE <br /> 'LUMBER WELL DRILLER\DDRESS ADDRESS m 0 <br /> CI 0 <br /> o' , <br /> 'HONE PHONE z " r <br /> DESCRIPTION 4. Sanitary Facilities: ° 0 ° <br /> I. Work: 2. New Building Details No. Bathrooms o <br /> New Building Type of Construction: No. Bedrooms 0 <br /> Addition Septic Tank Size Gals. <br /> Sanitary Size ft. x ft. <br /> Filling Height Stories 4a. Absorption Field Site: <br /> Moving Area Soil Type o <br /> Grading Slope - <br /> Mobile Home 3. Use (describe exactly, 1 -family Perc. Rate <br /> Privy home,garage, motel, etc.) <br /> Dry Well <br /> Well Seepage Trench (Y; <br /> Subdivision .0"" Privy "kb- <br /> Seepage Bed <br /> cn <br /> -ocation of proposed structures and existing structures,well,sewage systems,roads,etc.,should be sketched in Fig. A. Include road . ('vJ <br /> etback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- °- <br /> ection, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING < <br /> N <br /> ;TRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. p' <br /> t <br /> i. Lot Size: Fig. A. 6. Location: <br /> ft. x ft. — sq.ft. <br /> co <br /> ,57,16./ a./77/4—.:1-e-,61a7Y7)7 0 0 .--.' <br /> X-0\ - 9 , Pa�.,se-. a►5 , 1 ?. <br /> o_ <br /> .- <br /> o 0 h —I <br /> o <br /> I <br /> /''� <br /> rc V S <br /> T (\)si m <br /> `p <br /> C73 <br /> o <br /> z <br /> A, toca <br /> F <br /> f' <br /> I x cnr �* cncoz <br /> Ca) C 3 _. fp 3 C CD <br /> Q Q,G -r+< iE <br /> -a .C d �' TI <br /> C)n H < to * m <br /> z o• `p : : E. xi <br /> 0 <br /> in <br /> N <br /> m <br /> o <br /> >ignature of Owner or Agent Date i C <br /> x)iemarks C m <br /> m <br /> c " I <br /> i 0 <br /> � y <br /> nspection Date ;e , ' <br /> d +� t 1$ 0 0 0 0 0 cn m <br /> Zoning Administrator A-f o o 0 0 0 o Vmi <br /> OTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> afore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> Iis 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 he made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />