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77 77 <br /> 3urnett County Office of Zoning Administrator 3 o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT <br /> o <br /> rO THE z'bNING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as c <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use co CD <br /> Jrdinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 o- <br /> M.��e h <br /> 0 <br /> CD <br /> CD <br /> JWNER (please print) CONTRACTOR or SURVEYOR or AGENT a <br /> igU[✓ o <br /> ADDRESSADDRESS v � <br /> ........................... ........................................................................... <br /> ADDRESS <br /> ADDRESS <br /> .............. .......................................................................................... <br /> PHONE PHONE <br /> ........ .. ........... ...... .... <br /> ............................................... <br /> ...... ........ ....... ...... ...... <br /> PLUMBER WELL DRILLER <br /> 0 <br /> .......................................................................... <br /> ADDRESS 6'[5 R—E,SS- <br /> CDp <br /> —• < <br /> PHONE PHONE <br /> N <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> 1. Work: 2. New Building Details No. Bathrooms <br /> No. Bedrooms <br /> New Building 3 <br /> .,••,,,,,. Type of Construction: <br /> Addition Septic Tank Size Gals. .......... <br /> .................................................... <br /> Sanitary x Size .............. ft. x .............. ft. <br /> Filling Height ht............. Stories ............... 4a. Absorption Field Site: <br /> Soil Type ........... r <br /> Moving Area <br /> GradingSlope .......................................... <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family <br /> Perc. Rate ................................... <br /> Privyho e, arage, motel, etc.) Dry Well <br /> ��je," �ce., �t+�....... Seepage Trench .......... � <br /> `J <br /> Well ,�5.. ,...�.... S <br /> )tiV � Privy .......... <br /> Subdivision .......... .................................................... <br /> Seepage Bed .......... o <br /> ---------------------------------------------------- Y 01 <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road `J1 <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- r o <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> N <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. W o <br /> O <br /> ---------------------------------------------------------------------- : <br /> 5. Lot Size: Fig. A. 6. Location: :� l k <br /> ft. x .............. ft. — ............................... sq.ft. ............................................................................... :( <br /> cn <br /> C^ 0 <br /> 0 <br /> z <br /> z <br /> 0 <br /> v <br /> CD <br /> �n <br /> c S._ ID <br /> N o6 o � E <br /> a cn <. C : °CD <CZ <br /> IN 1 : rr <br /> z oofD `D7C <br /> � 3 <br /> cn — <br /> Q� o <br /> CD rr <br /> ... ...............'��. ........... Y ^�' ° C <br /> Signature of Owner or Agent C/ Date <br /> X <br /> „ ; rt <br /> Remarks .................................................................................. ......... II. ................................................... C C <br /> CD <br /> ....c-w Yr .....................tQ4i� _ <br /> . .............. <br /> ..........................�..... ... .... ... .... <br /> -�-• ..................................... <br /> �- �G c?LCt4. .......1.. ^'. .................................................. <br /> o <br /> Inspection Date ....................................... ....� .............................. 66 00 <br /> 0 <br /> Zonin dministrator o 0 0 0 <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary fa i itiw <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> this application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> with 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 />