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>? (,, l^ f <br /> Burnett Count X Office of Zoning Administrator o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> 0 <br /> CiF- <br /> TO THE ZONING ADMINISTRATOR'. The undersigned hereby makes application for a Permit for the work described and locat d as H <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Lan Use e) C <br /> m <br /> Ordinance Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin, 3 o' <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT a <br /> ...... . .. f .. ... .. . ... . ...1. ..... .� <br /> ,.. .....' ............................ <br /> ......................... .. ... ... ............ .... <br /> ADDIR�SS ADDRESS <br /> .I <br /> `�� C, 1. i� .. fly♦ <br /> a , <br /> m <br /> ADDRESS ADDRESS <br /> PH�........................... Y ................. .�....... <br /> �LV"'r]SS.'........... PHONE <br /> P.k... <br /> .......... <br /> .........................................PLU BER 'WELL DRILLER <br /> I ° o <br /> ADDRESS ADDRESS m 0 .� r <br /> n o <br /> o........................................................................................... .................................................................................... ....... ,» <br /> PHONE PHONE Z H <br /> r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details """ o <br /> New Building ..... Type of Construction: No. Bedrooms .. ..... n <br /> Addition vv ,.,,,,,,,,,.t;p.:............. ....., Septic Tank Size Gals. ........� `z t r <br /> ..A. .. .... ........... <br /> Sanitary Size ....�!?....... ft. x ..i::::,:... ft. <br /> 4a. Absorption Field Site: <br /> Filling/Grading ..... .... Height............. Stories................ <br /> . <br /> Soil Type ....................................Moving .......... Area .....: . :...:.: .. ............... <br /> �� <br /> Mobile Home .......... r Slope ..................................I........ <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Well .......... home,garage, motel, etc.) Dry Well ........., iT •MM <br /> Subdivision .......... - Seepage Trench .......... '�'V i <br /> Camping Unit ----------' Privy <br /> .......... ............l...c::,:.:.!.>......................... �'y� <br /> Seepage Bed ----- /4 .... <br /> ad <br /> Location of proposed structures and existing structures, well, sewage systems, roads etc., should be sketched in Fig. A. Includ road .� <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- if °- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection- CLEARLY LABEL EXIS ING <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> _------------------------------------------------ ----------------__— _ <br /> 5. Lot Size: Fig. A. 6. Location: ? <br /> ................ ft. x .............. ft. — ............................... sq.ft. ...............t..............:::.....X........................._..L........ P— <br /> IN <br /> —N O <br /> �phILI,IhTa.l Sflti.��-y ... C' <br /> 0 <br /> -o <br /> � o <br /> \2 <br /> d <br /> 0 Q m <br /> m a' ka d n =tNit <' C c <br /> - m <br /> z ca l n 70 <br /> ' F» — <br /> 'y'' 11v110 <br /> W o M <br /> JWC <br /> Signature of Owner or Agent Date X <br /> / : <br /> Remarks5.. �..(.. ..�:.�............................' ...................................................................................................L..... <br /> / C/ .rev '/• ' ... .......... ..... .. . ... .. . .. . -- <br /> Gl l G �<< <LCx� � :. ... <br /> .. . ... .... .. . . ...1. ........ .... .... .... .... .. ......... ...... . ............ .... ..... ..... . . . .. II <br /> N T <br /> Inspection Date .�......�.� ..... <br /> ............ ....... .......... -.l�Y._................... ..... ' v m <br /> }ldl m <br /> Zoning inistrator 8 8 8 8 8 H <br /> NOTE. A preliminary site inspection must be made and site approval granted on all structures involving sanitary facl � IS <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolatio n,test must be attached to <br /> this application before a permit will be Issued. Do not purchase or Install a septic tank, do any plu Ling or start any build <br /> Ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the int rmation conveyed here- <br /> with Is found to exist. Changes in plans or specifications shall not be made without approval of tl e Zoning Administratoi. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />