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On C r ) , <br /> Burnett County Office of Zoning Administrator '- - o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as '< H O kl <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 L <br /> Ordinance, Sanitation Code, nd with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin CD v� <br /> h) e h ' << <br /> y N <br /> OW,�'R (pleas rin CONTRACTOR or SURVEYOR or CD CD <br /> . ..�.a . . . Lis/ 3 VP3o �Z74 ...�1-t✓l s yri,,3 a <br /> ADDRESS ADDRESS . t) <br /> ai <br /> ADDRESS (if <br /> 3d <br /> ..W <br /> ,,,,i •- <br /> PHONE PHONE <br /> PLUMBER WELL DRILLER <br /> ADDRESS ADDRESS m <br /> 0 0 <br /> o ,-r 1:,.. <br /> PHONE PHONE z H • <br /> •— <br /> DESCRIPTION 4. Sanitary Facilities: . o 0 <br /> 1. 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 Type1(7 <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 /> Location of proposed structures and existing structures,well, sewage systems, roads,etc.,should be sketched in Fig. A. Include road 0 <br /> cr (No- <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 /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. ti <br /> o' <br /> I 0 N <br /> 5. Lot Size: Fig. A. 6. Location: e <br /> ft. x ft. — sq.ft. 1. <br /> � G00 z cn <br /> CD <br /> r. <br /> UQt • 9 1 - a a 0 ?. <br /> 3.5 <br /> LE' <br /> Cu <br /> H <br /> o <br /> 7 <br /> N <br /> N — <br /> t. T ‘,C,.,. <br /> z <br /> 0 <br /> Do <br /> 7 <br /> CD <br /> Do r7* co <br /> n . 0 - < = C CD <br /> (D 0_ • ,< - f-i Q <br /> N N -< co m <br /> z C o cD : : co xi <br /> 0 0 <br /> 5 E <br /> 01 CO <br /> No <br /> .X10 <br /> Signature of Owner or Agent Date <br /> X 70 <br /> Remarks m : m <br /> CD 0 <br /> iAl II <br /> 4 . <br /> N. <br /> ta <br /> Inspection Date ?frig-GO 9? ratc <br /> ' 0 m <br /> 1� 00000ccnM <br /> Zoning o 0 0 0 0 o Vmi <br /> 4OTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> iefore 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 /> vith 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 />