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Burnett Coucaty Office of Zoning AdminJ st ator v o z <br /> .-APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT h' 3 <br /> v TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as 0 <br /> •� — <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use - c <br /> CD <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and th laws and regulations of the State of Wisconsin. a <br /> r �� - <br /> ......:=........�!`.`. -........ ../r v �e- y o <br /> .............................................................................. <br /> OWNER (please print) ` CONTRACTOR or SURVEYOR or AGENT a <br /> .... .... ..................... ......... ................................................................................. <br /> A ICJ C)f1r1�( ADDRESS � <br /> `° <br /> ........1...............✓.......... :'....`.`....... . v' <br /> ADDRESS 1`• <br /> _ 0ADDRESS <br /> ........................................................................ <br /> PNE PHONE <br /> PLUMBER 1� <br /> WELL DRILLER <br /> ADDRESS ADDRESS m <br /> o <br /> ............................. .j: o, c <br /> PHONE PHONE ` z H r <br /> DESCRIPTION 4. Sanitary Facilities: E <br /> 1. Work: 2. New Building Details No. Bathrooms .... ..... ^ � o <br /> New Building �( No. Bedrooms / :Q m :*, <br /> Type Construction: �. .� <br /> Addition i"q "rho Septic Tank Size Gals. �1v; <br /> Sanitary .. ... Size ..... � .�ft. x .... .. ft. 7•cF••• \: <br /> Filling / 4a. Absorption <br /> .......... Height..../..•..... Storles ...�... ption Field Site: <br /> Moving .......... Area ...... ? Z Soil Type .................................... n. <br /> 5.1'.. ........... yp r <br /> Grading e .Slope ° <br /> .......... p <br /> Mobile Home .......... 3. Use (describe exactly, 1 family Perc. Rate ................................... <br /> Privy .... ho e,garage, motel, etc.) Dry Well <br /> Well fC �f(r Cu'7f tt Seepage Trench .......... <br /> Subdivision „• S Privy p, <br /> Seepage Bed _ <br /> ................................................... <br /> --------------------------------------------------- --- :� /1 <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc., should be sketched in Fig. A. Include road :1 <br /> setback, side and back °yard dimension and location and setback from all bodies of water. If property is located at a highway inter- (tfl- <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. EK <br /> -� o <br /> ---------------------------------------------- /1' <br /> ———————————— <br /> 5. Lot Size: Fig. A. 6. Location: <br /> 1a <br /> f l.p......... ft. x ..2-0 ... ft. — ... �i:.G C G'........... sq.ft. � .. . pPr,►� <br /> Cn <br /> m <br /> o 3. <br /> 7 <br /> N ` - <br /> r+ <br /> L�ls T 7. <br /> C <br /> ° to <br /> CD <br /> .� <br /> W o <br /> � Wz <br /> CD <br /> 2 N Q Q•GCD <br /> '•F Q N <br /> Z O O Y <br /> En <br /> N :�>o <br /> , , <br /> 4- 4-"r........................ . .. ... .. ,� m <br /> Signature of Owner or Agent Date <br /> Remarks .... <br /> X M <br /> ... ..... -n m <br /> .. ./. .......7....... i.r.�a�.... CD . <br /> CD <br /> v <br /> .................................................................................................. <br /> o:. <br /> ................................................................................................... .. ......:.............................. �. ' II� N -n <br /> _, <br /> nspection Date ....................................... :.� o...�.. .... .., .................. t�: o 0 0 0 o 01 m <br /> " 00000bm <br /> Zoning Admini�frator <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 />