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<br /> Burnett County Office of Zoning Administrator a, CD 0 0
<br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT �. .
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<br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as H N.j
<br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use CD c .0
<br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances1-fr t:-.' 11)( 1—.4 01) leo .,_/
<br /> and the lar 1--ws and regulations o ,„ ,„,
<br /> f the State of Wisconsin. a.,_ ,i,.., �1 J
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<br /> OWNER (ple se print A CONTRACTOR or SURVEYOR or AGENT CD
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<br /> ADDRESS % ADDRESS 1 k
<br /> ADDRESS ADDRESS
<br /> PHONE PHONE „•
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<br /> PLUMBER WELL DRILLER
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<br /> ADDRESS ADDRESS n 0
<br /> PHONE PHONE Z y
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<br /> DESCRIPTION 4. Sanitary Facilities: •o o o
<br /> 1. Work: 2. New Building Details No. Bathrooms o
<br /> New Building Typeof Coqstruction: No. Bedrooms / o
<br /> Addition ...................... Septic Tank Size Gals. �:
<br /> Sanitary Size I4 ft. x ..tr(-`J�, ft. �'' N,
<br /> Filling Height.... Stories l 4a. Absorption Field Site:
<br /> Moving Area ./'...1.�...?...f.. - P Soil Type r
<br /> Slope o
<br /> Grading t\ '*
<br /> Mobile Home 3. Use (describe exactly, 1 -family Perc. Rate
<br /> Privy home,garage, motel, etc.) Dry Well 5V
<br /> Well _Ail C Seepage Trench r
<br /> SubdivisionU Privy
<br /> . .,� ./� �z ".. �4?... Seepage Bed kS rN
<br /> y'Location of proposed structures and existing structures,well, sewage systems, roads,etc.,should be sketched in Fig. A. Include road . I E `
<br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- r
<br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING n y
<br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. , o
<br /> 5. Lot Size: o
<br /> g/) //I : > Fig. A. 6. Location: tit
<br /> /.V.(j) ft. x ..1X l/�/.: ft. — sq.ft. C �c,
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<br /> Signs,r, v e of • er or A nt Date
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<br /> O Zoning Administr r 0 0 0 0 0 0 fm/)
<br /> \elimlnary
<br /> site inspection must bemade and site approval granted on all structures involving sanitary facilities
<br /> cuction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to
<br /> \' before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build-
<br /> Sit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here-
<br /> -ist. Changes in plans or specifications shall not be made without approval of the Zoning Administrator.
<br /> _____,-.1M SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED.
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