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C.' % ??q <br /> Burnett County Office of Zoning Administrator v - o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT o <br /> TO THE AbNING 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 :W <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. a <br /> R..nl H � O <br /> . /. . ........... .............................� ................ .......... ... . ... ...... ..........��.......... . -......... `_ <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT Q %1 <br /> � .... m <br /> ...... .............................................. ............................................................................................ a _ <br /> ,gy <br /> ADDR S ADDRESS <br /> CD <br /> ........................................................................... <br /> ADDRESS ADDRESS <br /> PHONE PHONE <br /> . . . . ................................................................................... <br /> PLUMBER WELL DRILLER <br /> ............................................ ........................................................................................... <br /> ADDRESS ADDRESS 0 o <br /> . ........... . . <br /> PHONE PHONE <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details " """ <br /> New Building ... Type of Const tion: No. Bedrooms '?.... <br /> Addition ••.••••„• u?. ?: ','. f 'f?? ,.,...,..,, Septic Tank Size Gals. ..........` <br /> Sanitary Size ..!1 k..... ft. x :'`.`? ..... ft. .......... <br /> / / 4a. Absorption Field Site: <br /> Filling ,,,.,,,.,, Height.... ..... Stories ............... <br /> Moving /� Soil Type .................................... : r <br /> Area 1........`tr............................ o <br /> GradingSlope .......................................... <br /> Mobile Home .......•.. 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Privy x.., ome,garage, motel, etc.) Dry Well <br /> Well �, � �• Seepage Trench ... <br /> /.. ... ....... Privy f <br /> Subdivision .......... p, :ew, eY�e ••• �} ` <br /> .. .�.`.... ....��'.......... _- y.Seepage Bed y� <br /> Location of proposed structures and existing structures,well, sewage systems, roads,etc., should be sketched in Fig. A. Include road <br /> setback, side and back s <br /> yard dimension and location and setback from all bodies of water. If property is located at a highway inter- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING y• <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. p' A <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size* t' Fig. A. 6. Location: d <br /> ft. x'13p....... ft. — (2. ...�...... sq. ft. 'F5 .... +ZhG..... ((4 <br /> 4.V67 , V CD <br /> Lo <br /> 1 my o. <br /> ° <br /> „ <br /> ate ' <br /> itix+s3n«5 -jr�7 G .�i o i>. <br /> Z <br /> CD <br /> FC' W ILI <br /> F"ss • <br /> t t M cn r- :p M co Z <br /> CD <br /> sZ3 � E CD <br /> m. Naa< — + o <br /> 0 -0 cn <. C : ° 5' 'o <br /> ti : 'M rn <br /> t i a o y o, `° <br /> ..............�77 ....:.................... ... ........... :'.. .... <br /> Signature of Owner or Agent Date — <br /> t x �J X Qu <br /> IL ' /5 tRS s'f o al !V� / i? y{' A�? s n M <br /> Remarks( ! .. .f.4-...G !........... ............................., .......... ............. ............................. . ......I...........................• , �►' :o <br /> p <br /> ID <br /> ..../..!�?./i.'.Lc4;;n�S".../-:��.".!.!�..N....G?�j„',.�12��s�..c.���.."?r;�...�cs,i/,CY9N'�•:,�.. ��:.. .^.`:�.....�. .`�.�� <br /> R °. ?... ! ..... rr�5 i � isrz ,�c�1e %,� +e 1 ,SE j�fk'G ✓�s' <br /> t,Q <br /> Inspection Date ....................................... .�'- " ...... m <br /> Zoning Admini ator o o o N <br /> VOTE: 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 /> :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 /> n+ith is found to exist. Changes in plans or specifications shall not be made without approval of the Zoning Adm inistrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />