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Burnett County Office of Zoning Administrator J z <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use 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 /> Q <br /> ...Q......W. /•.:.:...•/. ............................................ ...:.•.. ...... � l S 1 ��.................................. NCO <br /> OWNER (please print) CONTRACTOR or S RVEYOR or AGENT CD <br /> ,y <br /> / /E C� n <br /> A RESS ADDRESS / °t <br /> ......................................... <br /> ADDRESS ADDRESS <br /> sy� � <br /> ........................ <br /> PHONE PHONE <br /> .......... <br /> .................................................. 'W"'E-..L....D.RI...... ........................................................... <br /> PLUMBER WEL LLER.... <br /> ADDRESS ADDRESS <br /> CD <br /> 0 o <br /> ............ z 0 r <br /> PHONE PHONE <br /> DESCRIPTION r <br /> 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms ....... .. r� o <br /> New Building Ty e of ConstLuction: No. Bedrooms 0 .R <br /> Addition .X , 1.1. Septic Tank Size Gals. <br /> Sanitary ........., Size ....t?4.Q... ft. x ... ., ft. <br /> Filling Hei ht Stories 4a. Absorption Field Site: E <br /> g ............. <br /> MovingArea Soil Type - ; u <br /> Grading .......... lope .......................................... <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> 9� <br /> Privy .......... home,garage, motel, etc.) Dry Well <br /> Well Seepage Trench .......... <br /> .......... .................................................... <br /> Subdivision Privy .......... <br /> .................................................... Seepage Bed <br /> ---------------------------------------------------------------------- <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- I a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING < <br /> N <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. � p' <br /> ---------------------------------------------------------------------- 0 <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x ............. ft. — ............................... sq.ft. ............................................................................... <br /> D <br /> / c <br /> �C <br /> z <br /> 6MV)� r <br /> _. CD E <br /> mt O <br /> * m <br /> z' oofD � �° 70 <br /> o �. <br /> L <br /> 0 <br /> / I o M <br /> .............................. <br /> ]nature off Owner or Agent Date X <br /> marks_.>ek 7*z .......................................................................................................................... m M <br /> co <br /> Co <br /> t <br /> .................................................................................................................................................................................... u <br /> ........................................................................................... ... ........................... . <br /> spection Date �Yt�'O < z'.��� .. c� o 0 0 o M m <br /> ...................... i o0000 <br /> Zoning AdmiKistrator rc' 4 ( 0 0 0 0 0 Cn <br /> TE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> ore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> In is found to exist. Changes in plans or specifications shall not be made without approval of the Zoning Adiministrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />