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i <br /> Burnett County �, Office of Zoning Administrator C - o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ' 3 <br /> �* o Q <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as H it <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use CD C ?OG <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 CL <br /> P�cKkA <br /> ......j <br /> ............................ .............................................. ............................................................................................ y <br /> OWNER-(pplleaase print)) t CONTRACTOR or SURVEYOR or AGENT a <br /> ../...!T.. ..K.1. /........................................ ............................................................................................ <br /> ADDRESS ADDRESS ;y <br /> i <br /> �. ... ..�.� ©. ............................................................................................ <br /> ADDRESS ADDRESS <br /> ........................................................................................... ............................................................................................ <br /> PHO PHONE <br /> y <br /> ........- .............................. ............................................................................... <br /> PLU B R WELL DRILLER <br /> ......................................................................................... <br /> ADDRESS ADDRESS <br /> 5 .-..y : —......................................... ............................................................................... o 14, <br /> PHONE PHONE z <br /> r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms ` o <br /> New Building ... ,. Type of Construct No. Bedrooms <br /> Addition ........ u�GQD. . ................VOC. Septic Tank Size Gals./Iwo. <br /> Sanitary Size .. .... .. ft. x Z/O... ft. .......... � <br /> Fillingf 4a. Absorption Field Site: <br /> Height....//. . ,pit ries,............... n <br /> Moving .......... Area ..../... . . ... Soil Type ... <br /> ............... <br /> Grading Slope ° c <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family Perc. Rate ...... ............................ <br /> Privy h e,gara e, motel etc.) Dry Well .......... <br /> Well x.. ...0FFi Seepage Trench .......... <br /> Subdivision Privy <br /> F� � ....-�T415 Seepage Bed ~.... <br /> ---------------------------------------------------------------------- D Cf, <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- '� o <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. N <br /> 5. Lot i e: �� �0 Fig. A. 6. Location: Sr <br /> a. ft. x ft. — ...........0 .............. sq.ft. ............................................................................... <br /> co <br /> r, Cn <br /> ,5,,XZj57 4 rr4 cf4 F40 o 0 <br /> _o <br /> r+ <br /> �i 2 <br /> CD <br /> 0 <br /> c <br /> ID <br /> CD <br /> M cncoz <br /> n 6 7 C• <D C cD <br /> 0 <br /> Z 00 fD C <br /> o <br /> o0 70 <br /> l-:........................................ .��. ..... s <br /> Signature of Owner or Agent Date <br /> • x 70 <br /> „ m <br /> Remarks ......................................................................................................................................................................... CD 0 <br /> CD <br /> ........................................................................................................................................................................................ <br /> ............... . .................. . ..... . .......................................... � <br /> Inspection Date ....................................... ................. . o 0 o cn <br /> g . ..... <br /> Zonin Ad nistrator 66 0 0 o C <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 /> ✓vith 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 />