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3urtiett County Office of Zoning Administrator 0 CD 0 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 /> ;hown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m C �O <br /> Drdinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 o Q <br /> Q <br /> OICL0. <br /> CD <br /> O J R (plea print) C&,-� OR or SURVEYOR or AGENT � <br /> ram...L.,94X... Q........................................... <br /> 4DDRESS RE ADDSS t CD <br /> . . ...,..� �........ ..y�7.�................................ <br /> 4DDRESS ADDRESS <br /> .......................................................................................... ....................................................................................... ` <br /> 'HONE PHONE.... <br /> .......................................................................................... .................................................................................... <br /> 'LUMBER WELL DRILLER <br /> ........•. <br /> ....•..................................................................................... .AD......D.RES"*E'S"................•............................••..................... 1 <br /> 4DDRESS S CD G) <br /> 0 o <br /> o' <br /> 'HONE PHONE Z H r- <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details """"" ` o <br /> New Building Type of Construction: No. Bedrooms .......... <br /> Addition Septic Tank Size Gals. .......... <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... <br /> Filling Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Area Soil Type ....................................Grading o <br /> Slope .......................................... <br /> .......... 0 <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> PrivyDry Well ......... <br /> ,........, home,garage, motel,etc.) <br /> Well Seepage Trench .......... <br /> Subdivision ✓.... Privy .......... <br /> .................................................... Seepage Bed <br /> ---------------------------------------------------------------------- to <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- 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. p' <br /> ---------------------------------------------------------------------- _ 5�— <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... <br /> �� A <br /> J _ �� '� � CD <br /> c <br /> i N O <br /> .ij vjj <br /> -� o <br /> H <br /> -nCD <br /> ^C <br /> i <br /> 1 (_u , O <br /> in <br /> �o <br /> �o r - NooZ <br /> dC CD <br /> T. O_ QG '+'O <br /> N N G :E m <br /> OLTI <br /> CD <br /> o C <br /> Signature of Owner or Agent Date — <br /> X 70 <br /> Remarks -n ` 'CD <br /> 11 <br /> ........................................................................................................ ...... ............................................... �1 <br /> -nInspection Date ....................................... �rt c 0. o 0 0..................... ............................... \� H 0 o cn m <br /> Zoning Admi Istrator "C o 0 0 0 0 o Vs <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 />