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Burnett County Office of Zoning Administrator 3 o o <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 ti o <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land UseCD <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> r+ <br /> °- O <br /> Sr y °.r..ie`......./r....�i .a.s .y............................ ...............F..................................................................... <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT M CD <br /> a <br /> �OX y <br /> ADDRESS ADDRESS rt <br /> ADDRESS ADDRESS <br /> 9'6 y17 c <br /> :S" <br /> ............ <br /> PHONE��r PHONE <br /> s ............................................................................. ........ ... <br /> PLUMBER WELL D..RILLER <br /> v <br /> ADDRESS ADDRESS m <br /> o 35' <br /> ............ —' <br /> PHONE PHONE 3 � <br /> DESCRIPTION 4. Sanitary Facilities: ° o - <br /> 1. Work: 2. New Building Details No. Bathrooms ....�.. r\ ; <br /> New Building .. Type of Construction: No. Bedrooms . <br /> m <br /> Addition ✓'� f/P,¢..,,r„ Septic Tank Size Gals. . <br /> Sanitary .......... Size ...>/A..... ft. x ./ ..... ft. .......... <br /> Filling .......... Height..l3..... Stories ...1,,,,,.... 4a. Absorption Field Site: <br /> Moving Soil Type .................................... ; <br /> .......... Area .....�/..6.....s. ....f..� ........... , r <br /> GradingSlope .......................................... o <br /> Mobile Home 3. Use (describe exactly, 1 family Perc. Rate ................................... <br /> Privy .......... home,garage, motel, etc.) Dry Well <br /> ........ <br /> Well �i— <br /> /J, p Seepage Trench .......... <br /> .......... .........e4.I�...../!�... ...................... <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 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 /> J1 H' <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. ' o <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> XAq'l.'. ft. x .............. ft. — ....................... sq.ft. ............................................................................... / 3 <br /> C <br /> s� h <br /> Ov1s/� D o �. <br /> jog <br /> o <br /> '— <br /> o ?- <br /> :R <br /> CD <br /> �o rn rncoz <br /> Cl) C m -2. C d c m <br /> CD PQ <br /> CL <br /> LT, m 5 p � <br /> D b < <br /> ay.W � � g m <br /> z oo'D <br /> oo��.al <br /> � �. <br /> ................... ........................... �. �.. ..:... c <br /> signature of Owner or Agen Date ° <br /> X <br /> 3emarks ...P....44',ttiC.W.4.!K ...y ...�.�''...ei.!�A. .pr.......�R....�ai✓..1.�1! ..,t�i.Q.�n................................................ v <br /> CD <br /> JEO <br /> . .....4 .ia... .3.................................................................................................................................... <br /> .................................................................................................... ... 'I N T <br /> .. : O: 00000cnrrt <br /> nspection Date ....................................... I o 0 0 0 0 0 m <br /> Zoning Admmistrator��JI�: o 0 0 0 0 o N <br /> OTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> More 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 /> g 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 />