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nett-G'ounty Office of Zoning Administrator Cn d -aCD o fz <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT h 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as H o <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. m <br /> IN- <br /> 3 CL <br /> 4. <br /> se�ljc <br /> . 040AU...........I.............. ......................... ............................................................................................ y C <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT a <br /> . . ........�.e�.....��.................................... .... <br /> ADDRESS ADDRESS <br /> S V <br /> /..~�.v....5..........,.....E-t .......................................... ........ <br /> ADDRESS ADDRESS <br /> o................... 1 <br /> PHONE 41 <br /> PHONE <br /> �t 2 - 776 <19/ 7 wo <br /> ............ ............................................................................................ <br /> PLUMBER WELL DRILLER <br /> ........................................................................................... : : <br /> ADDRESS ............................................................ CD <br /> .............................. <br /> ADDRESS <br /> rt o <br /> ONE................................................................................ . . ................................................................................ <br /> PH PHONE :z o• rf <br /> DESCRIPTION r <br /> 4. Sanitary Facilities: ° 0 ° <br /> 1. Work: 2. New Building Details No. Bathrooms <br /> New Building ,.......•. Type of Construction: <br /> No. Bedrooms <br /> Addition ...,•••„••.... Septic Tank Size Gals. .......... <br /> SanitarySize ...... .. ft. x ... . ... ......•••• <br /> .......... r .... ft. <br /> Filling „•, Height..... . .. Stories ....�.......... 4a. Absorption Field Site: : <br /> SoilT e .................................... 1 <br /> Moving .......... Area Type R o <br /> Grading Slope .......................................... <br /> .. <br /> Mobile Home ,,..,..,,. 3. Use (describe exactly, 1 -family <br /> Perc. Rate ................................... r <br /> Privy .....•.... home,garage, motel, etc.) Dry Well .......... <br /> Well ........., . Kcr. �C'qo� See a e Trench <br /> p 9 <br /> Subdivision Privy <br /> .......... <br /> Seepage Bed .......... 14� .Wn <br /> ------------------------------------------------------------ ----- Z cn <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- ( a <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. T. <br /> 0 <br /> ---------- ------------- -- ----- -------------------- �c <br /> 5. Lot Size: Fig. A. 6. Location: �J <br /> /. SSO ft. — sq.ft. <br /> P� <br /> Cn <br /> C <br /> 0 <br /> 1/2' <br /> 0 <br /> 0 <br /> 3 <br /> a <br /> 130 o 2 <br /> 'FR4.1[[ , CD <br /> �o <br /> s.T. <br /> t <br /> � csv dWZ <br /> m <br /> go - d <br /> 6N. y � ngm <br /> O 05 m cn M <br /> / S <br /> cn <br /> M PA L4I 70 <br /> :b� <br /> a ... .... ......p....... - 3 p <br /> ................ �► c <br /> Signature of Owner or Age o <br /> Date <br /> Q ....................................... r <br /> � x <br /> Remarks .iFv /UI /cf_ —n 77 <br /> ........................................................................................... CD <br /> 0 <br /> CD <br /> t <br /> ........................................................................................................................................................... ............................ — <br /> :p : <br /> ............... h <br /> Inspection Date ....................................... Zoning Ad �— la: 0 0 C o Ln m <br /> .... .�.. ......... ........ <br /> in' trator SS0000U) <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 he made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />