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Burnett County Office of Zoning Administrator 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3. <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as H \ <br /> ;hown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m m <br /> UrdQN18 <br /> ce, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin, a :Q <br /> Ga 3 _ <br /> ............... ...... 5 ........................... ............................5.1 .......................................... N n1 <br /> (please print) CONTRACTOR or SURVEYOR or AGENT M Q <br /> m <br /> /..,D P....S........, .... 5.... ............................................................................................ a o <br /> 4DAR ESS /) yy�� // ADDRESS °1 <br /> . o a... �y ...........................................................rl o <br /> ................................................................. .......................... <br /> 4DDRESS ADDRESS ` <br /> lz..........yas' <br /> �H EPHONE................................................................................ <br /> L� i <br /> O1Jj.(�j.........l.T ................................................. ......................................................................................... <br /> 'LUfvIBER WELL DRILLER <br /> .......................................................................................... . ...... . . ............................................................................... <br /> 4DDRESS ADDRESS <br /> o :n <br /> ............................................................ P.. ................................................................................... o <br /> SHONE HO....N..E O <br /> DESCRIPTION 4. Sanitary Facilities: / �° o ° E� <br /> 1. Work: 2. New Building Details No. Bathrooms R \ o <br /> New Building .... Type of Construction: <br /> No. Bedrooms <br /> Addition .... ... „•.... „•� � <br /> Septic Tank Size Gals. <br /> Sanitary XSize ... ft. <br /> Filling .... ..... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area Soil Type .................................... <br /> Grading Slope .......................................... ° <br /> yt <br /> „C <br /> Perc. Rate ................................... <br /> Mobile Home ,,,..,..., 3. Use (describe exact) , 1 -family � <br /> Privyhome,garage, motel, a <br /> Well h.. Dry Well <br /> Seepage Trench .......... <br /> .. .. ........ .. <br /> Subdivision ��iz.... . e.,Te Privy <br /> �+w G- i9—BU Seepage Bed <br /> --------------------------- ----- ---------------------------------- 0 <br /> _ocation of proposed structures and existing structures,well,sewage systems,roads,etc.,should be sketched in Fig. A. Include road t `� C7 <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- CL <br /> ;action, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> H A <br /> iTRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. —' <br /> 4 :C-1 <br /> i. LQQt``{��' e: Fig. A. 6. Location: <br /> L...�..... ft. x J. O'ft.— ............................... sq.ft. ............................................................................... <br /> A.. <br /> 4 � <br /> N O <br /> ;o <br /> 11 '' T <br /> ° Z <br /> d <br /> �.— <br /> tnry W <br /> M. Na 'a< <br /> OH m < sc <br /> 0 00 <br /> O 7 - <br /> O <br /> i2m <br /> .C.... .............................. ..-..1 .-8'l , a <br /> Sign ure of caner or Agent a I _- <br /> Date <br /> /� �; — <br /> Remarks .. ... % fYC '!..4 !�....f�.. ?(�Y —�tt'',II.l X :o i <br /> . ....... ............ /.. /.y 5,4 ; m <br /> ..........s .. . ................................. ... ...................... .... . ... <br /> . <br /> 'g o o.O Lncn <br /> mmInspection Date�. . .6.. . ......... o ... . ... .............. <br /> Zoning Administr for ✓ ooo cfl <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 /> its application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> tg 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 />