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. r,---n C c,)cf`)_ <br /> Burnett County Office of Zoning Administrator —I Z <br /> APPLICATION FOR SANITARY LAND USE — BUILDING PERMIT 3. ' <br /> O <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as ch ° O <br /> W <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 with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> fRo.b <br /> OWNER (please print) a CONTRACTOR or SURVEYOR or AGENT a \ co <br /> ...2 tm1 EA..0 C�LI4It <br /> ADDRESS ADDRESS <br /> a 7if L11Qr <br /> ADDRESS / ADDRESS ''c.' <br /> 1 <br /> PHONE PHONE <br /> -7 1�— P.3.11.5. 7� -co. <br /> PLUMBER WELL DRILLER <br /> 0 <br /> ADDRESS ADDRESS o o r�5 . t- <br /> PHONE PHONE Z cn (— <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details o �i <br /> New Building Type of Construction: No. Bedrooms a 431 <br /> Addition Septic Tank Size Gals. <br /> Sanitary Size (p.. ft. x r ft. 1' <br /> Filling Height..� ' Stories 4a. Absorption Field Site: <br /> Moving Area Soil Type o <br /> Grading Slope 4-- <br /> Mobile Home 3. Use (describe exactly, 1 -family Perc. Rate \ <br /> Privy ....,.. home,garage,motel, etc.) Dry Well <br /> Well Seepage Trench f <br /> Subdivision Privy 'sk <br /> Seepage Bed <br /> 9-i cn <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road s <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- ( °• <br /> • <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. S. o <br /> 5. Lot Size: Fig. A. ,.0 <br /> ft. x ft.— sq.ft. <br /> V ''� �ci z e 5 <br /> QN ....IO' <br /> ro c <br /> I <br /> 5 y.l <br /> 0 <br /> N <br /> n•� h o <br /> H <br /> `V 0 <br /> _' <br /> f -0 <br /> n T <br /> t CD 0 <br /> Z \�. <br /> N. O <br /> ]] <br /> N <br /> t0 <br /> CD <br /> 1 <br /> A <br /> I SO <br /> L3-6 ID <br /> Ivy mq g S fC C r a� rn co <br /> c �°- <br /> , <br /> cp. <br /> N ;'Q <br /> ° •CJ ° r <br /> 0 <br /> Z o5 D <br /> e <br /> NI o <br /> N <br /> 1` O r <br /> 1E, V. lk ali <br /> Signature of 0 fit or Agent Date X <br /> -11 Remarks co C <br /> ft <br /> \bTi :It <br /> \� <br /> Inspection Date ���' ae-4444-J o boo r <br /> O.o r <br /> Zoning Administrator o, o 0 o C <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 />