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v,7 2v <br /> 1 <br /> Burnett County Office of Zoning Administrator o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> o \ <br /> TO THE ZONING 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 CD C ;(p <br /> Drdingnce, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. a <br /> -' -- <br /> !' 1 <br /> DWNER (please print) CONTRACTOR or SURVEYOR or AGENT M <br /> ............................................................. ................................................ ............................... \ <br /> 4DD ESS / ADDRESS <br /> ADDRESS ADDRESS <br /> ............................................................................. ............................................................................... �1 n <br /> PHO E PHONE <br /> , C�'fc7�<�......'l.�.d.�7�C`�`s ...................................................................... <br /> ............................................... <br /> PLUMBER WELL DRILLER <br /> l . .......... ...............................................................................ADDRESS ADDRESS CD 0 <br /> :� 0 O ` <br /> ........................................................................................... <br /> PHONE PHONE Z r <br /> DESCRIPTION 4. Sanitary Facilities: ° o` <br /> ••••Bathrooms r ^ <br /> 1. Work: 2. New Building Details No. Bat � o ' <br /> New Building Type of Construction: No. Bedrooms .. .� .. �J ' <br /> Septic Tank Size Gals. 3N1 1 <br /> Addition /C700 <br /> •<Sanitary .... Size .............. ft. x .............. ft. .......... <br /> Filling .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area Soil Type .................................... io r <br /> GradingSlope .......................................... <br /> .......... <br /> Mobile Home ••........ 3. Use (describe exactly, 1 -family Perc. Rate .............................j... <br /> Privy home,garage, motel, etc.) Dry Well .......... <br /> Seepage Trench .......... <br /> Well x.... ILI <br /> Subdivision .......... /r)<� Privy .......... <br /> ........�l...9. . ..............'�........ Seeps a Bed �. <br /> j w <br /> --------------------------------------------------����>ILL.� tLL�a N <br /> Location of proposed structures and existing structures,well, sewage systems, roads,etc., should be s etched 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 < <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. 0' <br /> ------------------------------------------------------------ ----- <br /> 5. Lot Size: Fig. A. 6. Location: g <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... Q <br /> ti <br /> m <br /> N O <br /> O 7 <br /> 7 <br /> cn <br /> r-r <br /> .1 <br /> a <br /> 0 <br /> CDD <br /> � TCD <br /> Nr1 % 0Z <br /> CD C N _ N C (CD <br /> -O C71 < 'Z <br /> o N N M <br /> Z 00 ID . `D 70 <br /> :Q\o <br /> o �p <br /> ........................................................................... ...................................... o c <br /> Signature of Owner o,r Agent Date X <br /> /.. �P ................................................................................................................... T <br /> Remarks Fl / � �."�" t� _ f1•� CD ; ; it k: <br /> ......................................................... <br /> 1 " �� � � m <br /> Inspection Date ......�: c?!/ '>• ••••... • o 0 0 D o m <br /> ......................... .................. <br /> Administrator : : o o o 0 0 fn <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 /> roith 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 />