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Burnett County Office of Zoning Administrator C - o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT h 3 <br /> v ;: <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 a <br /> 1✓...... T D.V. . ✓........................................ ............................................................. o <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT ro <br /> a <br /> .[..`(..�....Ti...� 4.. ..1�, .i- ?.tz. .....�..- ....... .......... ................................................................................. Q <br /> ADDRESS ADDRESS <br /> ADDRESS ADDRESS <br /> PHONE PHONE :� <br /> .................................................. L....... <br /> DRI............................................................................. <br /> PLUMBER WELLLER <br /> :0 <br /> .......... <br /> ADDRESS ADDRESS CD o f6 <br /> ............. z o' �+ <br /> PHONE PHONE <br /> DESCRIPTION 0 <br /> 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details ......•••• o <br /> New Building ... Type of Construction- No. Bedrooms .......... -a <br /> Addition „•••,• ....• Septic Tank Size Gals. .......... ,.: <br /> Sanitary .......... Size ....L.?.... ft. x .....1...Z ft. .......... <br /> Filling4a. Absorption Field Site: <br /> .......... Height............. Stories ............... <br /> Moving .......... Area .....7 y- .. Soil Type .................................... o <br /> Grading Slope .......................................... <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 /> .................................................... Seepage Bed 4 <br /> ---------- ------- ------------- ----------------------- <br /> Cn <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc.,should be sketched in Fig. A. Include road 6 <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- Q <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 /> 0 <br /> 5. Lot Size: Fig. A. Is................ ft. x .............. ft. — ............................... sq.ft. Is <br /> fn <br /> CD <br /> CoOO r " <br /> .:N o• <br /> o <br /> n <br /> d <br /> N : <br /> �+ rF <br /> 0 <br /> 141 S <br /> g ' <br /> Z <br /> i 2 0 � <br /> i <br /> i j:CA,�� <br /> 0- 3 < :3 S. <br /> m NQQ< im <br /> o cn < <br /> L. O o O• (D <br /> o � <br /> C <br /> .. J "'ti .. .. ...C � ..... - p <br /> ..... ........ .. .. <br /> Signature of Owner or Agent Date T x m <br /> Remarks ............................................................................................................................................................................ ° C <br /> ........................................................................................................................................................................................... <br /> ....................................................................................................... .................Q.......f. . ../.............................................. :'l 4 <br /> Inspection Date ....................................... -9- A Zonin o g.. .... .. .. o 0 0 0 o m <br /> Adm� for J 0 0 oIo Cn <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 plumhing 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 />