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r it <: Y7L( <br /> Burnett.County Office of Zoning Administrator 3 0 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT co . o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < N -^ SJ <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use ;IF (�( <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 - t\`� , <br /> 6),„ ..,/, 4 /19. etelf.a.) 7 ,..,.7 r, <br /> th <br /> 2/441:e#A1 <br /> OWNE (please print) CO TR• TOR or SURVEYOR or AGENT o_ f, <br /> ` <br /> ADDRESS AD RESS 2- Vt <br /> � , Ai/ t51f7� <br /> ADDRESS ADDRESS <br /> PHONE PHONE iQ <br /> PLUMBER WELL DRILLER `k <br /> v <br /> ADDRESS ADDRESS o G) <br /> o o <br /> o -.- <br /> PHONE PHONE Z N r <br /> DESCRIPTION 4. Sanitary Facilities: P o ° <br /> 1. Work: 2. New Building Details No. Bathrooms o <br /> New Building Type of Construction: No. Bedrooms g Nc <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.) Dry Well <br /> Well Seepage Trench <br /> Subdivision i/ Privy <br /> Seepage Bed <br /> cn <br /> Location of proposed structures and existing structures,well,sewage systems,roads,etc.,should be sketched in Fig. A. Include road a <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- o <br /> • <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> Vl <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o' <br /> z <br /> 5. Lot Size: Fig. A. 6. ocation: <br /> ft. x ft. — sq.ft. it.N..X44?-r?1.1 C5/17 2616r j' . 5I'35,R <br /> i . <br /> Off' oC2 ,4 <br /> �Gf/ i 1 I o 0 <br /> JU-o-0-4-.--.-r-a., 4 , `t-v.' a►1 V\ UZ Ul <br /> c G 0 o <br /> oQ cc c ) :-' <br /> ( i o <br /> 0 O Q <br /> CD <br /> DJ <br /> 0 <br /> CD <br /> o c •C <br /> 7o r *N CO Z <br /> c� � m <br /> z = m : : EMI <br /> 0 <br /> o <br /> N o X) <br /> �a m <br /> Signature of Owner or Agent Date o C <br /> X Xi <br /> Remarks ( (3 m <br /> n <br /> Voo <br /> Inspection Date �2�ilc�/� �� ` o 0 0 0 o cN m <br /> Zoning Admi rstrator /c, 1 000000ccn <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 plumping 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 />