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Burnett County Office of Zoning Administrator C - o 0 <br /> a) <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT S <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use CDI CD <br /> c <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a (t . <br /> OWNER (please print)p CONTRACTOR or SURVEYOR or AGENT <br /> a n '� <br /> 4DDRESS � ADDRESS <br /> ........................................................... ADDRESS.. ............. ............................................................................ (�1 <br /> ADDRESS • <br /> ...............�.��o. . �f13c'...................................... <br /> 'HONE PHONE <br /> . . . .... <br /> 'LUMBER � WELL DRILLER ��• : <br /> .� r. ..1....................... ............................................................................................ .� <br /> ADDRESS ADDRESS % o <br /> < <br /> ....................................... <br /> PHONE PHONE <br /> z H r <br /> DESCRIPTION 4. Sanitary <br /> Facilities: ° o ° <br /> 1. Work: No. Bathrooms �° <br /> 2. New Building Details ......•••• <br /> New Building X. Type of Construction: No. Bedrooms t .. <br /> CD <br /> Addition Septic Tank Size Gals. �S� :� <br /> Sanitary ....x ., Size ft. x ...3. ft. � � q <br /> Filling .......... Height......$.... Stories ..../......... 4a. Absorption Field Site: :(p <br /> Moving .......... Area 74f?t ?..................... Soil Type ............. <br /> Grading Slope ...................... ..... .Q........ <br /> o <br /> Mobile Home 3.�seescribe exactly, 1 family Perc. Rate .....................!.... .....Priv •....•.•.. garage, motel, etc. Dry Well .......... <br /> Welly •, . Seepage Trench <br /> .............4.!mK ....Cf}. 1n1...... <br /> Subdivision Privy ........ <br /> . . ............................................. <br /> -------------------------------- Seepage Bed /8 XZ3.. (... <br /> --------------------------------------- N <br /> Location of proposed structures and existing structures,well, sewage systems, roads,etc., should be sketched in Fig. A. Include road 0 <br /> 6 <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- CL y <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. H <br /> 9 T� <br /> 5. Lot Size: �-Fig. A. 6. Location: <br /> ................ 57 <br /> ft. x .............. ft. — ............/...........-..r sq.ft. t................. .................. ... U1 <br /> CAI <br /> 0 <br /> 0 \ o <br /> W =LO <br /> U "I <br /> CD <br /> O <br /> .1 7 <br /> 71y cfl <br /> Nr � MZ <br /> a < m E- m <br /> sv <br /> a cn < C : E' er <br /> r' H ti G Lo <br /> Z o o `D CD <br /> oto <br /> CD <br /> (li o <br /> /..........( �o c C <br /> Signature of Owner ent Date <br /> x <br /> Remarks .......f C <br /> ............... CD T . <br /> CD <br /> ....... ./.j.)..:........................................................................................................................................................................ <br /> :t^ <br /> 6�0..........(/,.y '1..:.:-b."............................................... . ............ . ......... ........................................... c C <br /> �.� .` <br /> Inspection Date vZ U .. ....... �` ...�.... `f...... �' ':::........... 1° 0 0 0 o Cn m <br /> .................... <br /> Zoning A inistrator 0 0 C 0 0 N <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 /> ,)g until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> ✓ith 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 />