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Burnett County Office of Zoning Administrator 0 CD 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT �' n <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as H o :W <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use mCD <br /> e Y <br /> � <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a O <br /> . .r..r... ..... �.................... ............................................................................................ CC <br /> N � G <br /> OWNER (please p i t) CONTRACTOR or SURVEYOR or AGENT a <br /> ..... <br /> 1....3...o..c�.. ... ....7..er„a-....Dh.l.......... ........................................................................... <br /> ADDRESS ADDRESSIT <br /> �* <br /> ............................................................................... <br /> L" <br /> ADD ESS ADDRESS c <br /> ............. . . <br /> 'HONE PHONE <br /> —........................................................................................ <br /> .......................................................................................... . . . . <br /> 'LUMBER WELL DRILLER ?cam <br /> v C <br /> .......... <br /> .A..D.........S..S.................................................................... �. <br /> 4DDRESS DRE C o <br /> r+ < ` <br /> PHONE <br /> .......... O................................................................................. z r /1 <br /> 'HONE <br /> DESCRIPTION 4. Sanitary Facilities: ° 0 ° <br /> Bat <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details ......•• o <br /> New Building .......... Type of onstruction: No. Bedrooms .......... D <br /> Addition v IG ..•.•„ Septic Tank Size Gals. <br /> M. <br /> Sanitary ....... Size . ......... ft. x .../;V 1� .*... ft. <br /> Filling Height Stories 4a. Absorption Field Site: <br /> g Soil Type .................................... r <br /> Moving Area ........................................... <br /> Grading 9 Slope . ` ° <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Privy ho e,gara e, mo I etc.) Dry Well .......... i <br /> o Seepage Trench <br /> Well .......... ... ... ...a�l......C!r!�...�l <br /> Privy <br /> Subdivision .......... ...IG�/.4.5?`�.. ... . . ............ �)J <br /> ...... j '(A <br /> Seepage Bed <br /> ---------------------------------------------------------------------- (n <br /> Location of proposed structures and existing structures,well, sewage systems, roads,etc.,should be sketched in Fig. A. Include road a S� <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- l _a <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. o' °�rA <br /> 1 v,----------------------------------------- <br /> 5. Lot Size.; S Fig. A. 6. Location: <br /> ........... ft-=.. ............................... sq.ft. ............................................................................... CD <br /> i <br /> 0 <br /> L 0 <br /> o <br /> 40 <br /> Poi <br /> CD <br /> Y 7 <br /> U) Cn co Z <br /> 5CD C <br /> 4 C, <. c CD <br /> T. Nan.< — rr a � <br /> O-0 LTI H. � < cn m <br /> Ul o Z o — � <br /> o 6r) �. <br /> ... .......................... o <br /> Signature of Owner or Agent Date �* <br /> X 70 <br /> Remarks T <br /> m <br /> CD <br /> CD <br /> ........................................................................................................................................................................................ : : : <br /> u <br /> ..................................'........`....... ...................................................... . ................ �� ini�ir�b�� <br /> .........................Inspection Date .�...!� ......... ! o m.. ........ ...................... C rQc� oZon E c!i o 0 0 C o cn <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 />