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Burnett County Office of Zoning Administrator d - o Z <br /> 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 <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use c� c <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin.L-Tkovyv s... -e� o <br /> ..t .................. ......................................................................................... y <br /> OWNER (please print) fD <br /> CONTRACTOR or SURVEYOR or AGENT C _ <br /> Q :0 CD <br /> DRESS ADDRESS ' <br /> �(, sS�37 <br /> h <br /> o.o ....... i .! ............ .................................. ......................................................................................... <br /> ADD ES ADDRESS "S <br /> v <br /> PHONE PHONE <br /> WEL........D..R............................................................................... �s <br /> PLUMBER L ILLER a :r <br /> .......... Q <br /> ADDRESS ADDRESSCID <br /> ' o <br /> 0 < <br /> ............ o' ,rt <br /> P H <br /> PHONE ONE z H <br /> DESCRIPTION r <br /> 4. Sanitary Facilities: ° o 0 <br /> 1. Work: No. Bathrooms 2. New Building Details .......... o <br /> New Building Type of Construction: No. Bedrooms o <br /> CD <br /> Addition • , �o.� ea...6� �( �x,� Septic Tank Size Gals. .......... '• :0 <br /> Sanitary .......... Size .......�J... ft. x .z�.... ft. .......... <br /> � .� <br /> Filling ..••...... Height.. ^�j.l 4a. Absorption Field Site: .� <br /> Moving .......... Area ........b.2- .: t.t.. Soil Type .................................... <br /> ........... <br /> Grading Slope .......................................... 'Cr, o <br /> Mobile Home <br /> .......... 3. Use (describe exactly, 1 -family <br /> Perc. Rate ................................... h <br /> Privy home,garage, motel,etc.) Dry Well ; <br /> Well Seepage Trench c <br /> ....iar..4r.4. .�...� c.e �..... <br /> Subdivision •....... Privy ........., <br /> 0. <br /> Seepage Bed .......... <br /> ------------------------------- d <br /> Location of proposed structures and existing structures, well,sewage systems,roads,etc., should be sketched in Fig. A. Include road c :O <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING < r <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> -------------------------------------------------- o :& <br /> -------------------- _ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> .Q....... ft. x 9 t0Q.... — q.ft. ............................................................................... :N <br /> Star o <br /> 0. <br /> C <br /> o = _ <br /> o p <br /> 1� I I „ '4\ <br /> f'4 ti- exist' ` <br /> w <br /> _ <br /> I4 -0 y`s 3� CD <br /> CD � <br /> L NQQ� C <br /> o 'H:y * m <br /> 0 Z CD <br /> CcCID M <br /> signature of Owner or Agent J Date ° C <br /> �, <br /> X 70 <br /> 3emarks -n : c c ; m <br /> ........................................................................................................................................................................ � 0 <br /> Gq <br /> u <br /> nspection Date ....................................... ..f....... ......... .......?�..... 0: o 0 o cn o u m <br /> ZoninggAdmor�� 0i o00 oofm/� <br /> OTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> afore 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 t)e made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />