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Burnett County Office of Zoning Administrator �' o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT . � 1 <br /> o <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 m <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 <br /> 7.p.� <br /> �--..4 71 r N s <br /> OWNER (ple e print) CONTRACTOR or SURVEYOR or AGENT v <br /> x. .. .Y.y......./........A....:................................................ W......... ..... <br /> W .4 : <br /> A RESS _ ADDRESS cz <br /> 14 <br /> ADDRES#,vr AA ��U � ADDRESS <br /> ia ........... �. .-...3's.Y..»....1.. ..j.�.....:.�..r..t...l.Q Y............................................................................................ > <br /> N PHONE <br /> ....................................................... ......................................................................................... � <br /> UMBER WELL DRILLER ?� <br /> -C <br /> .................................... ....... v <br /> ADDRESS ADDRESS.. m 0 <br /> Q-PrP i �/o 1Crus f o <br /> ................... d............... ........ ..... .......�.......... .Z o' <br /> PHONE PHONE ICt` a <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details """"" o • <br /> New Building No. Bedrooms .C).... <br /> ......•„ Type of Construction: a ;- <br /> Addition ............']C!^�.�. ,,,,,, Septic Tank Size Gals. O � � <br /> Sanitary ...� Size ..a:�...6.. ft. x ...7..d.... ft. <br /> Filling .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area Soil Type .................................... O o c <br /> Slope ................ <br /> Grading .......................... �+ <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 /> ................................................... Privy <br /> Subdivision ....... .. <br /> .................................................... 61 <br /> Q t� <br /> Seepage Bed <br /> -------------------------------------------------- ------- I•U -- <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road Q <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING y <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. r\ o <br /> ------------ ------------------------------------------------------ <br /> 5. Lot ize: Fig. A. 6. Location: <br /> ..0.......... ft. x ..T..(1..�.. ft. - ............................... sq.ft. ............................................................................... � <br /> CD <br /> O � <br /> a ?. <br /> rF <br /> COCD <br /> N <br /> CD <br /> CD <br /> cni- v cnmZ <br /> CD 3E CD <br /> m <br /> OH; y zz ca m <br /> Z o o m fD 70 <br /> oLn <br /> .. . ............ ..... ............................................ ............................. o <br /> Signature of wn or gent Date <br /> —` m <br /> Remarks ...................L............................................................................................................................... <br /> _. . � o <br /> CD <br /> ..........................D..........r ................................................................................................................................ <br /> ................................................................................................................ ............... <br /> 6% <br /> �2 93 o0 0 <br /> InspectionDate ..f .............................. ................ . g .......... .............................. <br /> Zonin Adm' istrator :�e: o 0 0 <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 be made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />