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3urnett County Office of Zoning Administrator v CD 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT n <br /> o <br /> 'O THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as H :� <br /> hown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use CD C <br /> ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. a <br /> t�� / �* o► <br /> N [7 <br /> .!..� 't'.......... .t./ S..................................... .lV.L� .................... <br /> ' o <br /> DWNER (please print) CONTRACTOR or SURVEYOR or AGENT CD fD <br /> ........... .................. <br /> ADDRESS ADDRE CD <br /> ... ` .�. .... ..... . . ................................................. <br /> ADDRESS ADDRESS 4 <br /> .......................................................................................... ............................................................................................ <br /> 'H NE PHONE <br /> . .............�o�. .....r........................ s e...(... '................................................ <br /> 'LUMBER WELL�RtttER <br /> �. - W.......................................... ............................................................................ <br /> 4DDRESSf n Q ADDRESS CD o <br /> T.0`.'.................�........................................... ............................................................................................ o <br /> 'HONE PHONE Z N r Ln <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms 3' o <br /> New Building ... Type of Construction: No. Bedrooms m <br /> �r Q cvt -�' Septic Tank Size Gals. �66 � �+ <br /> Addition ...... ... ........ ............. . ...................... <br /> ,` <br /> Sanitary ?�,.. Size ..fir. .. ft. x ... �... ft. ""' W <br /> Filling Height............. Stories ............... 4a. Absorption Field Site: :b\ <br /> g Soil Type ........................... :0 <br /> Moving .......... Area ........................................... ......... p: r <br /> Grading Slope ...' �/ ° <br /> Mobile Home .......... 3. Use (describe exactly fami -� Perc. Rate .. .~..J..'...f......... k :(� <br /> Dry Well .......... 1 <br /> Privy .......... home,garage, motel, etc. 4 <br /> Well ? . Seepage Trench .......... <br /> Subdivision Privy .. :Z'J: <br /> .................................................... a) <br /> Seepage Bed <br /> Location of proposed structures and existing structures,well,sewage systems,.roads,etc.,should be sketched in Fig. A. Include road f1h 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- t9a _� <br /> Section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> N <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. [� p' <br /> ----------9Y�f7�-�--------- ------------------------------ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... :N <br /> b CD <br /> N P t O <br /> O 7 <br /> o <br /> N <br /> ' CO <br /> G <br /> : 7 <br /> r T <br /> CD <br /> ;0 7 <br /> �V D <br /> Cn cn m z <br /> CD C:n 6 7 (D 7 C (D <br /> LD N <br /> m <br /> Z 0 O `D (D 70 <br /> to <br /> _ �D m <br /> ..................................... .......... ... ..................... ....✓ .~W...... 0— <br /> p <br /> Signature of Owner or gent Date C <br /> X <br /> Remarks . ..... � CD <br /> CD <br /> o: <br /> CD <br /> .............. ............................... .......................................,..................................... •e: fA <br /> Inspection Date . .:�..1.`" `7........... a'!y,.t!?...(...: ..n.. .......... .... J......................... 0 m <br /> Zoning Ad istrator K_J o 0 0 o o fA <br /> DOTE: 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 /> vith 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 />