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Burnett County Office of Zoning Administrator c -0 --10 <br /> CD 0 <br /> 7 1 C <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <� <br /> 0 <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 UseCOc Q�, <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. CL <br /> / 3 .� t <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT CCD m <br /> ..,V.R64SS <br /> ......Ar'e ...7� ... 7 ........... .........,AD ADDRESS <br /> AEC� A�.i...........:.5—:5. �u................. ............s ............................................................. <br /> DS ADDRESS <br /> 2................................................ ......... y'.? -<................................................................. ,'ut <br /> PHONE PHONE <br /> 1 <br /> ................... ................................................................. ......................................................................................... <br /> PLUMBER WELL DRILLER <br /> .......... o <br /> ADDRESS ADD RESS <br /> CD � <br /> ........................................................................ ................................................................................... O <br /> ................... . <br /> PHONE PHON......E <br /> . <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> 1. Work: 2. New Building Details No. Bathrooms .......... : <br /> o <br /> New Building Type of Construction: No. Bedrooms <br /> Addition .......... � Septic Tank Size Gals. �; ;k <br /> Sanitary .......... Size .. ..... ft. x Ry... ft. v n <br /> Filling .......... Height............. Stories .....�........ 4a. Absorption Field Site: <br /> Moving Area Soil Type .................................... r <br /> .......... ........................................... . . <br /> Grading Slope .......................................... ° <br /> .......... . . <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Privy •..•„•••. home,garage,motel, etc.) Dry Well .......... <br /> Well Seepage Trench <br /> .......... .... . ,���............................. <br /> Subdivision Privy .......... <br /> .0 <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 � <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 /> C • <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> ----------------------------------------------- <br /> ----------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ....... ft. x 1 .... ft. — <br /> fN <br /> CD <br /> N s o. <br /> ✓.iw O : p <br /> D � \ <br /> o c�c <br /> rt � Q <br /> ^ 7rr <br /> V :� -n :W <br /> O <br /> m <br /> to <br /> CD <br /> CD c d �CCD ]am <br /> z <br /> CD, N a a1 - <br /> CD <br /> oy.c: � m <br /> Z CD0' CD <br /> 0 <br /> 15q <br /> L M <br /> m <br /> .�... . . .. . .......... ...... ....:...... ?.............. \- _ <br /> � <br /> p <br /> Signature of Owner or Ag nt Date ° C <br /> X 70 <br /> Remarks m c c .' `: m <br /> CD <br /> ....................................................................................................................................................................................... <br /> :O u <br /> ............... O N <br /> Inspection Date ....................................... � d.. ...yyaI o 0 0 0 o cn m <br /> Zoning Administr or X� o 0 0 0 0 0 <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 />