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Burnett County Office of Zoning Administrator 3 a, —I 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. d <br /> o TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as - W H <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use CD e ilA 'V <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. a <br /> M 11"C C 14 0 y _ . n 9 <br /> y - • 9 <br /> OWNER (please print) L CONTRACTOR or SURVEYOR or AGENT C Y>' a) <br /> 1 I. i 10 w q ‘4,�.v i\ ,4� R IQi3, <br /> -t -, <br /> ADIAP4ESS ADDRESS 2' <br /> ar <br /> \cl `l S Kt A. 5- 3 (I 3 , . <br /> ADDRE96 <br /> / S ]ADDRESS F.1 <br /> PHON (p./.. ..-...5�..3..�,, ^ �.d. PHONE v <br /> 'j C�J <br /> ~ <br /> PLUMB R WELL DRILLER /\ l .., <br /> 0 <br /> ADDRESS ADDRESS X C) o D <br /> r+ < <br /> PHONE PHONE z y r- <br /> DESCRIPTION 4. Sanitary Facilities: . o o <br /> 1. Work: 2. New Building Details <br /> No. Bathrooms .. W <br /> 0 <br /> New Building ..... ,... Type o.-Construction: No. Bedrooms �� sL, 7 <br /> Addition , rQ v`'� O Septic Tank Size Gals. <br /> Sanitary C./ Size .. 7 ft. x ft. <br /> Filling Height Stories 4a. Absorption Field Site: <br /> Moving Area Soil Type %'�, o <br /> Grading Slope .' <br /> Mobile Home 3. Use (describe exactl , 1 -family Perc. Rate .It <br /> Privy home,garage, motel, Dry Well ..-- <br /> Well Seepage Trench ,,,-.1 <br /> Subdivision Privy <br /> • <br /> Seepage Bed /g .° -': <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc., should be sketched in Fig. A. Include road Jvl 6- <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- 1 a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING N. < <br /> N <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. N o' <br /> 5. Lot Size: Fig. A. <br /> ft. x ft. — sq.ft. (s, <br /> cliN <br /> 11 7 a. <br /> h. <br /> /1 , N 0 <br /> 0 VI n <br /> / - —._. ._. . lefsbiC)5c, s: <br /> 3s' ,So <br /> 1- <br /> ci <br /> 0 <br /> r T <br /> Ott -n u:n <br /> 1u \:4( / co <br /> ems, c <br /> cu <br /> -- , <br /> CD <br /> et q ci 4...k.r.%. <br /> e: <br /> Do cnr _ *cn oo <br /> N NQQ< d, C• m <br /> o N'C <br /> z oo' `° E <br /> 0 z <br /> N -I <br /> o xl <br /> o m <br /> /�, 9-%�P� 0 <br /> CD <br /> Signature of Owner or W Date m X m <br /> Remarks <br /> Eft •G <br /> Cam' .a.,_Q�� � Eft m <br /> Inspection Date o 0 0 0 o m <br /> Zoning Administrator o 0 0 0 o cn <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 be made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />