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0n (:'tY)-1,1,:, n <br /> Burnett County Office of Zoning Administrator ;�' z o z <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ' ] 3 <br /> 7 TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as v, O,4 <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 /> . \ * <br /> ga % id . ) N <br /> NER (please print) CONTRA TOR or SURVEY R or AGENT a ��� co <br /> ADDRESS ADDRESS r °.' <br /> I \' 3.:Ci , <br /> ADDRESS ADDRESSt\ i <br /> PHONE PHONE N.N <br /> ,,,, c. <br /> PLUMBER WELL DRILLER �1 <br /> q <br /> ADDRESS ADDRESS c G) <br /> h o <br /> o' ,--..- <br /> PHONE PHONE <br /> DESCRIPTION z N 0 <br /> 4. Sanitary Facilities: . o <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details <br /> New Building Type of Construction: No. Bedrooms o <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 o <br /> Grading Slope <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 <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road 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- Q <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING c <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. H <br /> o' <br /> 0 <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ft. x ft. — sq.ft. <br /> °i,�' S� <br /> 1d S� oocl <br /> cn <br /> cp <br /> w , o <br /> 0 <br /> -7/r1" 9 / 9, - /9 3 9-i 2 \I <br /> ' O <br /> -5' <br /> � �. <br /> z <br /> o <br /> isu <br /> DO ptr -0*cnooz <br /> cD CED .7 <br /> 3 <br /> m, N Q a. '.cm_ <br /> < <br /> -6 •V. < c m 3. 0 12 <br /> o v v, < c0 m <br /> Z O 0 N : : N 70 <br /> O —Ea <br /> 3 = g <br /> \Z!IIJ <br /> v 0 "� <br /> 0 xi <br /> m <br /> J/- /1-Y3 o C <br /> gnature of Owner or Agent Date '- — <br /> X 73 <br /> emarks m Ai m <br /> . . p <br /> ffsm <br /> spection Date 94,4-27 /?: ,� 0 0 0 0 0 0 .cr lm <br /> Zoning Admini ratorA"� V o0000ocn <br /> )TE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> fore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> s application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> s until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> ill 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 />