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-e 77 <br /> Burnett Cc?ufity Office of Zoning Administrator C o z <br /> 0 <br /> •APPLICATIbN FOR SANITARY — LAND USE — BUILDING PERMIT rt <br /> TO �HE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as •< <br /> shown herein. Theundersigned 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. °a G <br /> t <br /> r: <br /> co 0 <br /> 1�11..... . ..q..r,Mur........ ..r`q..�c..r............................. ......................................................................................... <br /> OWNER (PI ase print) CONTRACTOR or SURVEYOR or AGENT CD m <br /> a <br /> r <br /> ADDRESS4 ''£ .....b....`l?.t'....... .r..sT...0............................... ......................................................................................... 0 - . <br /> ADDRESS c <br /> A...DRES..... ..S <br /> . .............................................................................. A.•� <br /> ADDRESS D <br /> ...............................;.......................................................... ......................................................................................... ` <br /> P NE PHONE <br /> y <br /> ' �!,./�..!.r........................................................... ............................................................................................ :' I <br /> PLUMBER WELL DRILLER lj� <br /> ADDRESS .AD.... ..RES"'E'S—S.............................................................................. :oCJ 0 <br /> D (q; <br /> n p <br /> r' < <br /> ........................................................................ .......PHONE.................................................................................. p <br /> PHONE N � <br /> DESCRIPTION o o <br /> 4. Sanitary Facilities: o - <br /> 1. Work: No. Bathrooms -n <br /> 2. New Building Details <br /> New Building Type of Constru�,tion: No. Bedrooms <br /> Addition ,. ,Cry/�.��••••.•. Septic Tank Size Gals. ......... <br /> Sanitary ... Size .............. ft. x .............. ft. JJ. 0 G 0 .......... <br /> Filling .......... Height............. Stories ............... 4a. ) sorption Field LSi�e: <br /> Moving Area Soil Type ..........�L..Q../.. . �h..j... <br /> ........................................... Slope .....................Grading �s� .T.......... ;a <br /> Mobile Home 3. Use (describe exactly, 1 family Perc. Rate ................................... <br /> 7 ; <br /> Privy .......... home,garage, motel,etc.) Dry Well o ; ` <br /> Well Seepage Trench ......... 3 <br /> Subdivision Privy <br /> : <br /> .................................................... r: : <br /> ---------------------------- Seepage Bed ......... <br /> lQ <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road / <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 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. q� <br /> ---------------------- j_ <br /> 5. Lot Size: Fig. A. 6. Location: : <br /> ................ ft. x ........ .... ft. — ........ ..................... s ft. : :hI <br /> v , CD <br /> c� �.,� # <br /> 1AP0 <br /> o <br /> O <br /> .Pin <br /> La <br /> d <br /> o y; H: `C Lin g m <br /> Z O O (D <br /> o <br /> 0 MI <br /> OQ b <br /> rn <br /> ..... - f.3 <br /> O ' .............. Csignature of Agent Date p <br /> remarks CD : : vm <br /> CD <br /> �� ............... <br /> .e� 1./i!�i � u <br /> ..................... <br /> nspection Date �.�•Q..� ..!....•••....•• Q�mto y . . o 0 o cNii M <br /> (/ Zoning Ad inistra or c(�� o CO 0 0 o y <br /> OTt� preliminary site inspection must be made and site approval granted on all structures involving sanitary face ities <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 />