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Burnett County Office of Zoning Administrator Cn d _ o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT h 3 <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as y * W <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land UseCDc "vJ <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. I a <br /> .... <br /> OWNER (please print) CONTRACTOR or SURV OR or AGENT a CD <br /> ADDRESS ADDRESS <br /> 1 � et�,.....V.i.5........ . ............................................ vNZ <br /> ADDRESS ADDRESS w <br /> ................ . ......................................................... 1 <br /> .................................... <br /> PHONE 3 PHON.E�{'�..�..R <br /> . .. .......... \VV <br /> PLUMBER WELL DRI. .LLE.R <br /> .......... p <br /> ADDRESS A E DDRESS CD o <br /> < <br /> ............. o <br /> PHONE PHONE z <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms <br /> New BuildingNo. Bedrooms .......... m <br /> .... T,,YYpe of Construction: <br /> Addition t r(�rn� . ...�r�YQ, „•„•,,,, Septic Tank Size Gals. .......... <br /> Sanitary Size ........ ... ft. x .. .... ft. <br /> Filling4a. Absorption Field Site: <br /> .......... Height............. Stories ............... <br /> Moving Area Soil Type .................................... <br /> ........................................... <br /> 0 <br /> Grading Slope .......................................... i <br /> Mobile Home 3. Use (describe exactly, 1 family Perc. Rate ................................. . <br /> Privy .......... home garage motel, etc.) Dry Well .......... <br /> Well Seepage Trench .......... t �� <br /> .......... .................................................... <br /> Subdivision „••.,, Privy .......... <br /> .....................I............................. Seepage Bed �U i <br /> ---------------------------------------------------------------------- e <br /> Cn <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- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING Q <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> ---------- ---------------------------------- <br /> v <br /> 5. Lot Size: Fig. A. 6. Loc, tion: <br /> C 5 /Yi <br /> ................ ft. x .............. ft. — ............................... sq.ft. .....................�..1...... ....c�.�..... ... <br /> C <br /> C <br /> n <br /> o ?. <br /> O <br /> a <br /> h <br /> o <br /> \� .1U N <br /> L: <br /> z <br /> 0 <br /> m <br /> D <br /> CD <br /> m <br /> �U <br /> t <br /> cmT � mW <br /> (D. N Q Q< — '+ i2 <br /> oN. C:: : c ' m <br /> z o o `D <br /> o — <br /> m <br /> Jwa.�. ../....wo w............................ ..: ' ............ o p_ <br /> Signature of Owner or Agen{J Date <br /> X <br /> Remarks ......................................................................................................................................................................... m t1q: m <br /> `D <br /> CD <br /> ........................................................................................................................................................................................ <br /> �I, <br /> ...................................................................................................................................... : , .. ......................... <br /> Ln <br /> Inspection Date ....................................... areO 1...:...��...Gl!�u o 0 0 0 6 m <br /> o000 m <br /> Zoning Adm nistrator/C j0 0 0 0 0 0 <br /> TOTE: 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 /> ig until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> iith 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 />