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Burnett County Office of Zoning Administrator V o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT h' g <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as rn o <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m c <br /> Ordinance, Sanitation Code, and wit all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> _ cf p - 0 /I// G f /�A '' a 0 <br /> I <br /> cp <br /> OWNER (please print) CONTR CTOR or SURVEYOR or AGENT a <br /> ZStiti 4(74 Ca V VirX 440fil. a <br /> A RESS ADDRESS <br /> 12w �/ L�J a, <br /> V ti.tV Le-••2—'— _,. '6---- 6 a i I r <br /> m i <br /> AD3ESS �J ADDRESS <br /> PHO4 <br /> fE 12� � 47 f 6.G.2 ' <br /> PHONE <br /> PLUMBER WELL DRILLER <br /> Cl. . <br /> ADDRESS ADDRESS <br /> CD 6-) <br /> h 0 <br /> PHONE PHONE z a '� <br /> r <br /> DESCRIPTION 4. Sanitary Facilities: •o o ° <br /> 1. Work: 2. New Building Details No. Bathrooms ,� "1 : <br /> New Building Type of Construction: No. Bedrooms CD <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 <br /> Grat4jng Slope A ,- <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 Privy <br /> Seepage Bed i <br /> v 0 <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road rs c <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is I ated at a highway inter- a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLE RLY LABEL EXISTING (V < <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ft. x ft. — sq.ft. <br /> N. <br /> N. cn <br /> 0 <br /> go <br /> .)o o <br /> // ).51 - 0 <br /> y <br /> H <br /> . O <br /> S <br /> 7 D <br /> T <br /> CD <br /> - 0 <br /> • DO <br /> 1, m <br /> I <br /> CD <br /> r <br /> oQ <br /> \ <br /> �J <br /> . <br /> -_,,�`� M Cr)r Cr)CO <br /> -z <br /> m C m C CD <br /> mNc < <br /> , o- - 7+o_ <br /> z oofD : : m <br /> 73T o �N. m <br /> .J�-/.... / f2 ? p— p <br /> Signature of ner or Agent Date ° C <br /> • <br /> X . <br /> Remarks -n <br /> co CD <br /> v <br /> Inspection Date 92ri41 • %1 o 0 0 0 o cn m <br /> ZoningAdmi istratorrr) 00000ow <br /> mm <br /> TOTE: 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 plumbing or start any build- <br /> 1g 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 be made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />