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Burnett County Office of Zoning Administrator C - —I Z <br /> o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as 0 <br /> shown herein. The ers( d agrees that all work shall be done in accordange with the requirements of the Burnett County Land Use CD <br /> Ordinance, Sanitat• and with all other applicable County Ordina?ces•and the laws and regulations of the State of Wisconsin. a <br /> ".! . '.......... ''.1' V`C'.Yl................................... ....Y.�'f �T '��.t.�..... (!!./..-C 11, /..�V <br /> 666 :a O <br /> OWNER (please print) CONT ACTOR or SURVEYOR YOR r AGENT m m <br /> ss '� ....... f .r.............'.. d �S y� �1�5 �� <br /> ``,,', <br /> AD ESD.q. .. vl� .... ,..... t... .. 1 :4................................ a % <br /> . , <br /> f ADDRESS <br /> ,.....� spy <br /> ADCiRESSJ <br /> +� ADDRESS ; 1 <br /> ...' .-.. ,0�.. ............................ ..................... �C - �,� <br /> PHONE :..............".T... .. ..................................... 1 <br /> R <br /> PHONE <br /> 'C•` <br /> PLUMBER t ....................................................................WELL DRILLER , <br /> .............. p <br /> ADDRESS ADDRESS �' o <br /> ct < <br /> y CD <br /> ............................................................................................ .................................. . <br /> PHONE o 0 '- <br /> PHONE z y <br /> DESCRIPTION <br /> 4. Sanitary Facilities: o 0 <br /> 1. Work: : 2. New Building Details No. Bathrooms <br /> New Building, Type of Construction: No. Bedrooms <br /> Addition .......... ► Septic Tank Size Gals. .......... ' <br /> Sanitary Size .............. ft. x .............. ft. .......... :^ <br /> Filling .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Soil Type .................................... <br /> Area <br /> Grading Slope <br /> o <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 /> ........ . .................................................... Privy „•,•,•, <br /> .................................................... : <br /> SeepageBed N---------------------------------------------------------------------- <br /> Cn <br /> ; <br /> Location of proposed structures and existing structures,well,sewage systems,roads,etc.,should be sketched in Fig. A. Include road 11-1 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- V Cr <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. o. ;\ <br /> ---------------------------------------------------------------------- :; 7 <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ...................................................... <br /> CD <br /> �- <br /> n <br /> I <br /> N <br /> T o <br /> At <br /> 11 <br /> C <br /> Z <br /> CD <br /> CD <br /> o- a T... CD <br /> CD 5 <br /> 4A00 <br /> .........:� ....... �` m <br /> .. . . ........ ° <br /> p <br /> ignature of/O�wner9or Age? Date O C <br /> emarks ..,0VVR......�-ft:&. .... �� G.-_ / X M <br /> ................. C 0 <br /> ............................................................................................................................................................................ <br /> O ° <br /> o� <br /> • O; � � —, _,DTI <br /> spection Date ....................................... 1.:......�n ;��� <br /> ................ 0 0 0 0 o cs m <br /> Zoni . . 0 0 0 0 00 Cn <br /> )TE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> Fore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> s application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> h 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 />