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Burrfttt County Office of Zoning Administrator C - z <br /> Co o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT rt 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as <br /> o <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use a) c <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. a • <br /> _ a • <br /> OWN R (please print) CONTRACTOR or SURVEYOR or AGENT a n, <br /> fit . . <br /> ADDRESS ADDRESS a, <br /> CD <br /> y <br /> l/V-,6STic:, wis- -sve93 <br /> ADDRESS ADDRESS i <br /> PHONE�7 PHONE li <br /> (.�s9 OA) 13' N.... pal! <br /> tA <br /> PLU BER WELL DRILLER O ` ,...,1 <br /> 1-71 <br /> 1 <br /> ADDRESS _ ADDRESS �' o <br /> PHONE PHONE <br /> DESCRIPTION 4. Sanitary Facilities: •o o <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details ••• ram, <br /> New Building Type of Construction: No. Bedrooms V1 <br /> Addition Septic Tank Size Gals Q <br /> Sanitary •,•e`•.• Size ft. x ft. +� <br /> Filling Height Stories 4a. Absorption Field Site: 4� <br /> Moving Area Soil Type .. /mod. AiVD W r <br /> Grading Slope Le (�` ° <br /> .,Mobile Home 3. Use (describe exactly, 1 Perc. Rate family <br /> Privy home,garage, motel, etc.) Dry Well �,,1 it <br /> Well / F2Tfii, HO/114 Seepage Trench <br /> Subdivision Privy a /X 5Z' I dQ <br /> Seepage Bed 4 "'` <br /> 6 �� .► � IA <br /> Location of proposed structures and existing structures,well, sewage systems, roads,etc., should be sketched in Fig. A. Include road E m <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 v 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. (4./ Q `o4 . <br /> o <br /> 5. Lot Size: Fig. A. 6. Location: rU" <br /> i/\ <br /> 111 <br /> ft. x ft. — sq. ft. ` I''‘ <br /> BCE- Tl TZc iT F/J 114-'v� IA'� C) <br /> 4 <br /> 0 <br /> N III o' <br /> 0 <br /> 4 <br /> 0 <br /> m- <br /> z k0 <br /> II <br /> CO <br /> (n <br /> m <br /> xi c 1 7 DO <br /> _. m c m <br /> 0, Naas - <br /> -o U1 <• c 5' CJ ID <br /> N N <br /> z oo' fD a D3 <br /> o 3 <br /> 13 - <br /> cn Lc <br /> �o <br /> 0 70 <br /> / (\- m/3 08 y 6\- 0 <br /> Signature of Owner or Ag nt Date ,. <br /> Remarks .d7�1 e-e3-1-A-€1' x • <br /> • P • rn <br /> CD Q v <br /> /j- ►o- • <br /> 4'X'4Z�t�z�.17 et) i1e. n <br /> O <br /> ii c,�T <br /> nspection Date —� �� �� 1� o 0 0 o cNr, m <br /> Zoning Admi 'c., 000 oofm/) <br /> OTE: 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 /> pis application before a permit will he 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 />