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Burnett County Office of Zoning Administrator v CD 0 0 <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 y <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 /> Dimn ce, Sanitation Code,and with all other applic le County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> ... ...�............Fj. .. ....ck.�l...:.................. . .l..,f ................................................. <br /> / ( ease print) CONTRACTOR or SURVEYOR or AGENT <br /> .....'.1.. ............ .......... '. . .......I.7................ ...... . ............................................................................... Q <br /> 4DDRESS ADDRESS °+ <br /> \` <br /> S �n J, m i <br /> ...v.!.........fir'.!....!r / ... .............. 5.......��`'�.....: .7, �. .... . . <br /> 4DDRESS ADDRESS <br /> DH^O PHONE M :^ <br /> ......................................................... ............................................................................................ <br /> 'LUM ER WELL DRILLER <br /> 4D6RESS ADDRESS............................................................................ G <br /> CD <br /> 0 O <br /> .............................................................................. ............................................................................... O rr <br /> 'HONE PHONE. . 3 <br /> Z r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° (� <br /> 1. Work: No. Bathrooms <br /> �• 2. New Building Details - <br /> New Building „•I`;•, Type <br /> Construction: No. Bedrooms .......... ti <br /> Addition r r 0 VVI Septic Tank Size Gals. <br /> ........ 'v <br /> ✓✓ .... .. ................................ .. <br /> Sanitary <br /> JS .... Size ....�. ..... ft. x ..a. .... ft. ' <br /> Filling .... ..... Height............. Stories ............... 4a. Absorption Field Site: <br /> MovingSoil Type .................................... � <br /> .......... Area .................................. �i o <br /> Grading Slope .......................................... 0 <br /> Mobile Home Perc. Rate ................................... <br /> .......... 3. Use (describe exact) , 1 -family � . <br /> Privy ••...•.... home,garage, motel, etc.) Dry Well .......... <br /> Well ... ......................................I............ �. <br /> Seepage Trench <br /> Subdivision Privy <br /> Seepage Bed .........y <br /> ---------------------------------------------------------------------- <br /> Location of proposed structures and existing structures, well,sewage systems, roads,etc., should be sketched in Fig. A. Include road fi <br /> :.�' 3. <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- 1 :Q a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> 0 O <br /> —' <br /> ------ ---------------------------------------------------------------- _ <br /> 5. Lot Sze: Fig. A. 6. Location: <br /> V......... ft. x ..�...� ft. — ............................... sq.ft. ............................................................................... i� C <br /> 1 � o 0 <br /> 3 <br /> C 7. <br /> 3 <br /> `A aa,� <br /> ra <br /> u v CnCD co z <br /> � < <br /> � DCD <br /> L N Q ? G Q <br /> oN: c ' m <br /> Z o o `D CD 7p <br /> v r" <br /> o C <br /> Signature o0-K <br /> Ag t Date — <br /> X M <br /> Remarks ... �......t..................... m ip, m <br /> 1........... �..�.�:�.z =-................................................................................................ CD <br /> o <br /> ................................... .............. . ...... ................................................ <br /> u <br /> .. <br /> Inspection Date� Zo <br /> ............ ::..:? .................... 000000m <br /> a. <br /> ning A minlstrator -: 0 0 0 0 0 0 f/) <br /> JOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> refore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be, attached to <br /> his application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> ng until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> vith is found to exist. Changes in plans or specifications shall not he made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />