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Burnett County Office of Zoning Administrator v - o Z <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT . <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < H O <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land UseCD <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. a :W <br /> .i 1. s...b.@.c.k.s .r ............................... ...... .a.k ..C�Q.r.�s - . o <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT a C\ <br /> ADDRESS ADDRESS <br /> !►:►1.h.��t !G1lS....../.!1.!k.................................................. ..! . ..... .f5............................. <br /> ADDRESS ADDRESS <br /> PHONE................................................................................ ...... ........a.R.3.................................................... <br /> PHONE <br /> 'W-E,' .....DR......... ..................................................................... <br /> PLUMBER WELL ILLER.. <br /> ............................................................................ <br /> ADDRESS 0 �„ <br /> ADDRESS <br /> h o <br /> .................................................................................. - <br /> PHONEPHON.E........................................Y....................................... o + _ <br /> DESCRIPTION o 0 o <br /> 4. Sanitary Facilities: o �+ <br /> v <br /> 1. Work: 2. New Building Details No. Bathrooms o <br /> New Building Type of Construction: No. Bedrooms .......... -G <br /> CD <br /> Addition ^••••• Se tic Tank Size Gals. <br /> II <br /> p <br /> Sanitary .......... Size ....l.y..... ft. x ....�'1..... ft. .......... v <br /> Filling g ( 4a. Absorption Field Site: (� i <br /> .......... Hei ht.....g..... Stories .... .......... <br /> Moving .......... Area Soil Type .................................... p i- <br /> ........................................... <br /> o <br /> Grading .......... Slope .......................................... � -��- <br /> Mobile Home ........•. 3. Use (describe exactly, 1 family Perc. Rate ................................... <br /> Privy home,garage, motel, etc.) Dry Well T....... . <br /> Well S.�.k�EQr1..... ' Seepage Trench .......... <br /> .!^�.1...... <br /> Subdivision .•........ Privy <br /> .................................................... <br /> Seepage Bed .......... i <br /> ---------------------------------------------------------------------- <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc., should be sketched in Fig. A. Include road �cn <br /> >etback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- •� <br /> >ection, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> 3TRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. i <br /> -------------------------------------------- <br /> i <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ./............. ft. x .............. ft. - ............................... sq. ft. <br /> QJ, m <br /> o o' <br /> o '>-Q I J� <br /> o <br /> Lz < <br /> ` CD'e., <br /> a <br /> cnry cncoz <br /> CD � M � C: CD <br /> N Q Q <br /> m <br /> r ^ Z oo CD m <br /> U �'+ o <br /> signature of Owner or Agent Date ° C <br /> ...... .. . ... ....... � .................. x <br /> iemarks . . . . X.e. m <br /> CD M <br /> CD <br /> ....................................................................................................................................................................................... -- <br /> ✓....�................................................. <br /> 7jcb) <br /> N -n <br /> nspection Date ....................................... o 0 0 0m <br /> .. .......Zoning Administrator�'7 o 0 0 0o fm/) <br /> OTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> More construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> its 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 />