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Burnett County Office of Zoning Administrator v � o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT v <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < o <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 a <br /> o <br /> ✓2O� C �0. <br /> _ Q <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT a ; CD <br /> 'R I s-her a , <br /> ...... . ................................................................................ .. .. -,................................................................................ <br /> ADDRESS A..DD..REESS � :04 <br /> T <br /> ............................... RESS E-S"S", <br /> ........................................................................... <br /> 1 <br /> ADDRESS ADD �-- <br /> ............ l''jj �p <br /> PHONE PHONE :W <br /> ............................................................................................ <br /> PLUMBER WELL DRILLER <br /> .................... <br /> ADDRESS ADDRESS m 0 Q¢ <br /> ... ......... ............ Q. '.P <br /> PHONE PHONE <br /> DESCRIPTION z H r <br /> 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details o <br /> New Building Type of Construction: No. Bedrooms <br /> m ; <br /> Addition .......... .................................................... Septic Tank Size Gals. .......... - ' <br /> . . <br /> ,•,z ,� <br /> Sanitary .......... Size ft. x ft. <br /> v: <br /> Filling .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Soil Type .................................... '\ o <br /> Area ........................................... . : <br /> Grading Slope .......................................... <br /> Mobile Home Perc. Rate ................................... <br /> .......... 3. Use (describe exactly, 1 -family <br /> Privy ..... home,garage,motel, etc.) Dry Well �* <br /> Well . Seepage Trench .......... <br /> Subdivision Privy <br /> ................................................... Seepage Bed ......... <br /> ---------------------------------------------------------------------- <br /> Location of proposed structures and existing structures, well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road C <br /> setback, side and back rs <br /> 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 )l! <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. N' <br /> yj <br /> ---------------------------------------------------------------------- <br /> C>� <br /> 5. Lot Siz Fig. A. 6. Loc ion: f_ <br /> pp l c <br /> ... ft. x .P� .... ft. — �..�1 ............. sq.ft. .............. ..�t...d'...Ktl..?:.......Rd:................... <br /> Q C <br /> CN <br /> ^ o <br /> P <br /> ✓gxay b <br /> 0 �^ Le <br /> la°`R 01 <br /> -n fir` <br /> o <br /> cnr -0:EcncoZ <br /> =. C � ECD <br /> cn < C : <br /> 0 y - •G g m <br /> Z C)O co fD <br /> O —7 <br /> .. /­kp <br /> ....... �o ; C <br /> Signature of Owner or Agent <br /> • X � <br /> Remarks -n 0 <br /> m <br /> 09' . <br /> ........................................................................................................................................................................................ -- <br /> ............................................................................................................ ............. <br /> _ TI <br /> Inspection Date ....................................... .............ILI <br /> a o 0 0 o o m <br /> Zoning ministrator : ' o 0 0 0 0 o to <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <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 />