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Burnett County Office of Zoning Administrator C - 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 <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 Q Q <br /> . .......CD...... a. ...�' 1... '................................................. y A ° <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT Cu " m <br /> .. .�........ t..... S.. ... :.Y.......................... : ,Q <br /> ADD ESS ADDRESS , (� <br /> CD <br /> .A. .DD.. .. .......................... <br /> ................................................. :N <br /> ADDRESS RES......S... <br /> ............ <br /> PHONE PHONE :� :5 <br /> ................................................................. <br /> W <br /> PLUMBER .E. . .... ....................................................................... � <br /> LL DR..I..LLER.... <br /> AD <br /> ADDRESS ..........ES..S.............................................................................. '� <br /> DR <br /> 0 <br /> PHONE ° <br /> ................................................................................ . . ................................................................................. o' <br /> PHONE <br /> DESCRIPTION ° <br /> 4. Sanitary Facilities: ° <br /> 1. Work: No. Bathrooms 2. New Building Details •••••....• <br /> New Building No. Bedrooms <br /> Type of Constr ction: <br /> Addition �ll�baCi l Septic Tank Size Gals. ......... <br /> ,� <br /> Sanitary �t�( y`i .......... .. <br /> .......... Size ..2,,. .t.. . ft. x .... .... .... ft. <br /> Filling Height....W...... Stories ... .......... 4a. Absorption Field Site: : <br /> Moving .......... Area ........el.C1.41V...................... Soil Type .................................... ` r— <br /> Grading .......... Slope ........................................ . ° <br /> Mobile Home Perc. Rate ................................ 3. Use (describe exactly, 1 -family 1 <br /> Privy ..,•„•... home,garage, motel, etc.) Dry Well ... ...... y1 <br /> Well ..•....... Seepage Trench .......... J <br /> Subdivision <br /> ---------------------------------- Privy <br /> ... 4!2t!�x........................ <br /> / Seepage Bed Location of proposed structures and existing structures,well,sewage systems, roads etc., should be sketched in Fig. A. Include road C: J <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 /> ----------------------- <br /> 5. Lot Size: Fig. A. 6. Location: y A <br /> ft. x .............. ft. — ............................... sq. ft. <br /> 1 <br /> O :�p <br /> O <br /> O Cl) <br /> m <br /> 0 <br /> ° <br /> t` z <br /> W ° <br /> LO <br /> 00 CD <br /> CD <br /> Z. <br /> �R <br /> �Lt tnr- - `D� cnooz <br /> / 0 C N N C N <br /> < � <br /> d <br /> Ct 6 c,,. z o <br /> o _ <br /> oto <br /> _ <br /> � o <br /> 7 Z— m <br /> .....',ignature of Owner or Ag Date ° C <br /> iemarks w. l/' .. .�d 0................................... -n X i m <br /> CD <br /> Co <br /> : v <br /> IG03, � <br /> .................................................................................................. ..................... :v . . . . . . <br /> ispection Date ....................................... 4.. ..... .� 2s2 ...,C 1................. 0 0 0 o cn rrn <br /> Zoning Administrator 0 0 0 0 I—A <br /> f/)DTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilitie <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 /> j 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 />