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3urnett County Office of Zoning Administrator 03 CD- o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> o <br /> f0 THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as ; -* l� <br /> hown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use c '� <br /> ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 cL <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT a CD <br /> .............................................................. ............................................................................................ C <br /> ADDRESS ADDRESS '+ <br /> . ..5. ........ ............................................................. ............................................................................................ <br /> a DRESS ADDRESS <br /> .............................................................................. ................................................................... ............. : <br /> 'HONE PHONE <br /> ..........SG . ..... L............................ <br /> 'LUMBER WELL DRILLER <br /> ...................................... ...... . ...................... <br /> ADDRESS ADDRESS -D <br /> _ at <br /> �` t' o <br /> Q................................................. _. < <br /> 'HONE PHON.E.......................................Y....................................... o <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> I. Work: No. Bathrooms <br /> 2. New Building Details o <br /> New Building Type of Construction: No. Bedrooms 1.... k3CD <br /> Addition Septic Tank Size Gals. cP�! <br /> .......... ...................... ........................... <br /> Sanitary �' Size ..� ^"Y` ft. x .............. ft. ' <br /> .... <br /> Filling .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Area Soil Type ......,5!}1..Y.{?................ o <br /> .......................................... <br /> Grading Slope ...............S...a...}}�........... <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family Perc. Rate ................. ..f.............. <br /> Privy •••.•....• home,/,ar,,e,.motel, etch] Dry Well .......... am'Wel► +'"'+ � Seepage Trench�... d ...... . ............. . . <br /> Subdivision Privy <br /> .......... <br /> Seepage Bed <br /> --------------------------------------------------------------------`- cn <br /> _ocation of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road <br /> a <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- t 1 o <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. I H <br /> o <br /> ---------------------------------------------------------------------- <br /> i. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — .� .. ...... sq.ft. ............................................................................... k-p <br /> `4- <br /> 0 <br /> N p <br /> o <br /> C 14 t U A'1 /y <br /> A <br /> I Zr <br /> -n <br /> CD <br /> 0 <br /> CD <br /> CD <br /> �C <br /> CD c nri nN m <br /> L• NJ <br /> a-<� h• <br /> o cn < C : * m <br /> z o o' ° " 70 <br /> o <br /> fCD M <br /> C <br /> . -� _ �o <br /> ,��2 .... ... �........... <br /> Signature of Owner or Agent Date <br /> X Q <br /> Remarks m M <br /> m �. <br /> CD........................................................................................................................................................................................ <br /> �\ u <br /> ....... .... ........................................ ej � 88 8� <br /> Inspection Date ••••••••.•yl ;¢a✓•••..•.•... : ` : 0 0 0 ' o o m <br /> Zonin Adm' istrator 1f'� i o 0 0 o o y <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 /> rith 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 />