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- CT L C65(/) <br /> Burnett County Office of Zoning Administrator 0) 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT <br /> - <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as '�11 H <br /> • <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m C1-... <br /> Ordin nce, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> 4) <br /> OWNER (please print CONTR CTOR or SURVEYOR or AGENT m CD <br /> cri <br /> ADDRESS Ap9RESS <br /> _)i'a 4); y ?72 <br /> ........... <br /> ADDRESS ADDRESS <br /> PHONE PHONE ll"�\ <br /> PLUMBER WELL DRILLER <br /> t'-- <br /> ADDRESS ADDRESS 0 0 <br /> C . <br /> O r• <br /> PHONE PHONE Z H r <br /> DESCRIPTION 4. Sanitary Facilities: •o c <br /> 1. Work: 2. New Building Details No. Bathrooms <br /> New Building Type of Construction: No. Bedrooms co <br /> Addition Septic Tank Size Gals. <br /> Sanitary Size ft. x ft. 14 <br /> Filling Height Stories 4a. Absorption Field Site: <br /> Moving Area Soil Type h <br /> Grading Slope <br /> Mobile Home 3. Use (describe exactly, 1 -family Perc. Rate <br /> Privy home,garage,motel, etc.) Dry Well Ur <br /> Well Seepage Trench <br /> Subdivision 4" Privy 6S <br /> Seepage Bed <br /> C,; (•• <br /> r» c, <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road c c C <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- c- <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. o <br /> ci <br /> 5. Lot Size: Fig. A. 6. Location: Z. <br /> ft. x ft. — sq. ft. <br /> CD <br /> __.f d, ,A,C11.4, e 57'2 1,_> 9-) cn <br /> o <br /> \,/o CA) ,,— _ <br /> _\ '!t ;T\ y I i h —1 <br /> cn <br /> I. I 1 -O <br /> OJ <br /> 71 z Z <br /> ( O <br /> M <br /> cm <br /> l ;,jl <br /> xo r �*Ncoz <br /> z. co S E."D <br /> 0 • < cc * m <br /> Z o 'D XI <br /> 3 <br /> w co � <br /> L/ N m <br /> Signature of Owner or Agent Date '* <br /> X 73 <br /> Remarks T (A.t m <br /> o <br /> CD <br /> n <br /> 44 <br /> Inspection Date 94?")-frue 7.,4 `o, o 0 0 0 0 m m <br /> Zoning Admini rator 1.- J '� o000oocml) <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> this application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> with 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 />