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Burnett County Office of Zoning Administrator d -a -+ Z <br /> CD 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT rt• 3 <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 <br /> Ordinance, Sanitation Code and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. a "J <br /> / h <br /> O <br /> . ... ...................................................................................... y v <br /> r'OWNER ( lease tl CONTRACTOR or SURVEYOR or AGENT CD : CD <br /> .... ` <br /> CL <br /> ADDSS .................................................... � <br /> ADDRE S <br /> t;6 t t7D, ADDRESS <br /> ............. ................................................................................... <br /> PHONE PHONE...... .'•��> <br /> PLUMBER .......................................................................... <br /> WELL DRILLER <br /> ADDRESS ADDRESS CD <br /> h o <br /> ................................................................................ ..... . .................................................................................... : o' < <br /> PHONE PHONE Z <br /> D <br /> ^ r <br /> DESCRIPTION o h o <br /> 4. Sanitary Facilities: o <br /> 1. Work: 2. New Building Details No. Bathrooms ...2 7 <br /> o <br /> New Building .•.....•„ Type of Construction: No. Bedrooms -o ; <br /> m <br /> Addition ••........ Septic Tank Size Gals. .......... <br /> Sanitary .......... Size ...... ft. x ...�..}.. ft. <br /> Filling Hei ht / 4a. Absorption Field Site:g ./...... Stories ............... p ; <br /> Moving .......... Area Soil Type .................................... : r <br /> Grading .......... Slope .......................................... ° <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Privy home,garage, motel, etc.) Dry Well ; <br /> ^, <br /> Well .... Seepage Trench✓..... .................................................... _., <br /> Subdivision .......... Privy <br /> Seepage Bed .......•„ <br /> Location of proposed structures and existing structures well,sewage systems, roads etc.,should be sketched in Fig. A. Include road N <br /> c <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- _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. T. <br /> o_----------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — sq.ft. <br /> ............................................................................... <br /> C <br /> CD <br /> O 0 <br /> 0 <br /> 0 <br /> y <br /> 7 <br /> (� TI <br /> to <br /> CD <br /> F1, <br /> Cl)rv� cnaoZ <br /> c a) �. c co <br /> Nac- = a � <br /> �0 <br /> ....... .. ............ ......... ...� ...... ..... 1 p <br /> ignature of Owner or Agent : : C <br /> o . : <br /> _ Date ,� _ <br /> X 70 <br /> iemarks .... ..:...1(/...3......................................................................................................................... . . o <br /> .......................,............•......................................................................................................................................................... <br /> �. u <br /> .................................................................................................... .... .................. . . . . . . <br /> c: <br /> Ln <br /> �spection Date ....................................... 0 " M <br /> f�.r -*—*............. ...9........ ......... .��................... 000000m <br /> Zonin Ad inistrator 0000000 <br /> m <br /> OTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> ,fore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> is 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 /> 'th 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 />