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Burnett County Office of Zoning Administrator C - --Izj <br /> 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> r0 THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < N °-h <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land UseCDc W <br /> Drdinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> o <br /> 1` . . !UN..[.�� a. 11.��.......................................................................................... <br /> " C <br /> N G <br /> AWN please print) CONTRACTOR or SURVEYOR or AGENT CD <br /> \�1 <br /> ESS DDRESS <br /> �DIDRES . ..1..'..tiK.. V <br /> / ADDRESS ' <br /> > .....:� ........ ...7.,5...tY.................. <br /> 'HONE PHON.E................................................................................ <br /> WELL <br /> . . . ....RIL- ' .. ..................................................................... ' <br /> 'LUMBER DLLER.. <br /> .ADDRESS............ .............................................................................. ; <br /> ADDRESS 0 <br /> h o <br /> H 7 < <br /> ....ONE.............................................. ... ................ .................... o : n <br /> 'HONE <br /> PDESCRIPTION 4. Sanitary <br /> Facilities: ° 0 <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details <br /> New BuildingNo. Bedrooms ° `y) <br /> Type of Construction: L <br /> CD <br /> Addition .......... .................................................... Septic Tank Size Gals. .......... <br /> Sanitary .. ....... Size .............. ft. x .............. ft. .......... <br /> Filling Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Area Soil Type .................................... <br /> .......................................... � o <br /> GradingSlope ....................................... .. <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... % <br /> Privy .......... home,garage, motel, etc.) Dry Well .......... 1'� <br /> Well L/ Seepage Trench <br /> Subdivision •••.••... Privy <br /> Seepage Bed 4�1 <br /> ------ ------------------------------------------------------ Y, c/) <br /> .ocation of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig. A. Include road 1:/` C <br /> �tback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- I o <br /> "ction, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> TRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. y <br /> ---------------------------------------------------------------------- t4$ <br /> Lot Size: Fig. A. 6. Location: <br /> ................ ft. x ft. I <br /> N <br /> 0 <br /> o <br /> 3 <br /> L' sty <br /> ° <br /> m <br /> ooz <br /> _. c CD <br /> z oN y . � � g m <br /> ID <br /> o 5 : <br /> l _ <br /> cn cfl —i <br /> 0 <br /> ut� <br /> gir <br /> ture of Owner or ent .J-- ?� .I- 'IV' `W Date <br /> ! X 70 <br /> emarks -n m <br /> � C <br /> ..................................................................................................................................................................................... <br /> ..................................................................................................... .. ............... .............. ....... .................................... <br /> ispection Date ....................................... I° C 0 0 0 o cNi m <br /> ZoningAdminis rator /�J 0 0 0 0 0 0 CA <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 plumbing 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 />