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Burnett County Office of Zoning Administrator o 0 <br /> .r APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as H 0. �' <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use CD �u11 <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a �( <br /> r+ — 1. <br /> ... . /..{�..... .. �. .�../....ri�..T.•i�.I.YT: h......i...:..� l YAW• aw y �"� • `O <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT C m <br /> a <br /> n s'r...... c�.r...✓. .r .......................... <br /> ADDRESS �•�• �! <br /> ADDRESS / ,rt :Q <br /> ADDRESS ADDRESS sQ <br /> P.. ...NE.... ................................................................................ <br /> PHONE HO.. <br /> ...D.RILLER............................................................................... <br /> S <br /> PLUMBER WELL <br /> r <br /> ADDRESS ADDRESS <br /> ............ <br /> - < <br /> PHONE P..HONE � h <br /> DESCRIPTION o <br /> 4. Sanitary Facilities: o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details ......•••• 0 <br /> New BuildingNo. Bedrooms ° <br /> ........ . Type of Construction: ` D ' <br /> Addition Septic Tank Size Gals. .......... <br /> Sanitary .......... Size ft. x ft. ......•••• <br /> .............. .............. <br /> Filling .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Area Soil Type .................................... <br /> .......................................... r <br /> o <br /> Grading .......... Slope .......................................... <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Privy .......... home,garage,motel, etc.) Dry Well <br /> Well Seepage Trench ....... <br /> ........ .................................................... <br /> Subdivision Privy .......... <br /> .................................................... Seepage Bed <br /> ---------------- -------------------------------- <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc., should be sketched in Fig. A. Include road 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. <br /> o' <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... <br /> ^�. <br /> I <br /> o � <br /> j� = <br /> Z <br /> 0 <br /> -, CD <br /> ?� 'KM cnr -gcnCoZ <br /> C 0)co <br /> �. CD C CD <br /> t7 � cNno- a< — :is0 <br /> 5 <br /> �Z O N o < (fl g m <br /> ID <br /> ° U1 <br /> m. <br /> c p <br /> signature of Owner or Agent Date C <br /> lemarks ............................................................. T :N i c '• v <br /> m....................................................................................................................................................................................... — <br /> ................................................................................................................ <br /> �-n <br /> nspection Date �--- o 0 0 0 0,cNsi m <br /> g.. ............. , a ,C c00000m <br /> � Zonin Adminlstr or 1 0 0 0 0 0 o cn <br /> OTE: 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 /> its 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 /> 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 />