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-r - <br /> 1 �• l <br /> BLjrnett County Office of Zoning Administrator W CD 0 o <br /> APPI4ICATION 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 y . <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use CD <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a _avl <br /> . p.... ......./...f.Q... ..Y�............................... .... AGENT .............................. — <br /> o O <br /> N CD c <br /> OWNE�lease p int) / CONTRACTOR or SURVEYORor CD `D <br /> .......................... ...... ................................................................................. <br /> ADDRESS ADDRESS D <br /> ... .... N ..�°......w y.......5.y.8U. .............. ............................................................................ � J <br /> ADDRESS ADDRESS <br /> PHONE PHONE :31) <br /> .v..+. .....tc l.. i v,js.d f..✓................................. y, <br /> PLUMBEyI �^ �".f �n f WELL DRILLER <br /> : /...` ..-5'.ti�.��.......5' �.Q �..r'......w.,2...... ............................................................................................ :� o <br /> ADDRESS ADDRESS CD o <br /> o <br /> PHONE PHONE z y r <br /> DESCRIPTION 4. Sanitary Facilities: ° 0 ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details ""./"" <br /> New Building .......... Type of Construction: No. Bedrooms <br /> Addition Septic Tank Size Gals. 7...1.... <br /> Sanitary ..!677:7: . Size .............. ft. x .............. ft. <br /> Filling .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Area Soil Type .................................... <br /> ........................................ <br /> • o <br /> Slope . .............. <br /> Grading .... 0..... ............. <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Privy Dry Well .... ... <br /> ... <br /> ••••,•„•• home,garage, motel, etc.) <br /> Well Seepage Trench �... <br /> ......... .................................................... <br /> Subdivision Privy .......... <br /> .......................................I............ - <br /> Seepage Bed .......... <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc.,should be sketched in Fig. A. Include road i 6 kl <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- o <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING t 1•. < <br /> A <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> ---------------------------------- ----------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x ft. sq.ft. <br /> CD <br /> N O <br /> o <br /> CD <br /> CD <br /> N <br /> r{ <br /> V 3 <br /> CD <br /> r <br /> cn r : rA z <br /> CD c �, c CD <br /> -o cn < m <br /> O N N <br /> z 00. fD CD 70 <br /> � 5 <br /> o <br /> 0 <br /> m <br /> 5�A; <br /> a 1 �.... `� p <br /> Signature o Owner or Agent Date <br /> �r �'4 Z' <br /> t: v -n x <br /> Remarks ........... ..,�:..Q......-....................................................................................................................................... � <br /> CD <br /> ...................................... — <br /> .�.L: t1- z/.4f. . !°4:L� �4'.......................... .......... .............................. o: -I <br /> Inspection Date ..V...:.1.. .:.. ..���....... G�m4�.�.......... ............ o 0 0 0 o m <br /> C: <br /> Zoning Admi is <br /> o o o o o v� <br /> .�.J... <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 />