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Burnett County Office of Zoning Administrator C - -� z <br /> O O <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT �» <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as H <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use c VO <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State CD <br /> of Wisconsin. CD n <br /> OW ........ .ease rin' ............................................................. • ...... y � •� O <br /> OWNER (Please rint) . . . . . . . .................................................... � .`: :� � <br /> CONTRACTOR or SURVEYOR or AGENT a :� g< <br /> .......DA .�..v..R.y..... ..(04 <br /> ADDRESS ADDRESS f h j <br /> ADDRESS <br /> ADDRESS <br /> ............. 'O <br /> .................................................... .............. H'".NE.•............................................. ,4u <br /> PHONE PH. ..................................... <br /> .................................................. .............. ........................................................................... <br /> PLUMBER WELL DRILLER <br /> '1; ;L 0 <br /> ...................................................................... .. . . .............................................................................. i _.ADDRESS <br /> ADDRESSCD <br /> C <br /> ........................ ..... .. .. .. . <br /> 'HONE PHONE 0 <br /> N <br /> DESCRIPTION z4. Sanitary Facilities: �.° o ° <br /> 1. Work: No. Bathrooms /. ..2. New Building Details <br /> New Building Type,,�f CCD <br /> Rnstruci�'on: No. Bedrooms ... °c <br /> T'"�.4 <br /> Addition •••• •,.•. •,.,,,1••, .• ., Septic Tank Size Gals. l 00.0 <br /> Sanitary3�, <br /> �r...... Size ...... •...... ft. x .2.0....... ft. .......... <br /> Filling .. ....... Height............. Stories ............... 4a. Absorption Field Site <br /> Moving Area Soil Type ..... ................ .. <br /> ........................................... <br /> Grading <br /> .......... Slope ........�.. .Q............... 1 N .w • <br /> Mobile Home ••......•• 3. Use (describe exactly Perc. Rate ...c�Dry Well <br /> Privy .... home,garage, motel, etc.) �I <br /> W <br /> Well Seepage Trench ......... <br /> ....................... <br /> Subdivision ............................. Privy •••.•..... <br /> Seepage Bed x..... <br /> ———————————————— l <br /> _ocation of proposed structures and existing structures, well, sewage systems, roads,etc.,should be sketched in Fig. A. Include road ' <br /> etback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- a <br /> ection, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> ;TRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. C _ T. <br /> ------------------------- 0 <br /> ---------- <br /> --- 3 <br /> ' Iz� Fig. A. 6. Location: <br /> ....... ft. x ..(ll40.... ft. — <br /> CD <br /> o <br /> _T: b W <br /> rt <br /> o <br /> n.�.�•fill �' <br /> m: <br /> CD (� <br /> z <br /> 70 o <br /> a� d <br /> D <br /> CD <br /> c cr � v iW v 1, <br /> CD <br /> Naas <br /> o' cn <' <br /> . c � <br /> z oy' CD � � I <br /> o <br /> U1 <br /> c) <br /> ...... ........................ .............. ................... <br /> gnature of Owner or Acient Date <br /> �)// X 70 <br /> emarks ...1 �.1. �... <br /> n m <br /> CD <br /> ..................................................................................................................................................................................... -- <br /> fNN u c <br /> ...................................................................................................... <br /> ............. <br /> „ <br /> ispection Date . .. .................................. c�zC �............. L: ,�--r.; ... ... :\' o 0 0'0 o cn m <br /> Zoning Administrator 0 0 cc 0 0 Cn <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 plumbinq or start any build- <br /> I until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> th 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 />