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Burnett County Office of Zoning Administrator 0) CD -IU z <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ° 3 o <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 undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land UseCDc <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a " <br /> '+ <br /> N. .. N s.o. ►............. '.................................... <br /> H � CD <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT n <br /> �o <br /> -s.. .... .... ... �Q !r ��. ..- a ,.......................................................................................... <br /> ADDRESS ADDRESS d <br /> mCD <br /> ........................................................................................... .. S'D.R.ESS.S",........................................................................... <br /> DDRESS ADDR : <br /> /...9.........75 .....`f.�0..7................................. <br /> ...................................................................................... <br /> ONE PHONE <br /> W E.......D..RILLER.. ...... .. ..................................................................... <br /> PLUMBER LL <br /> p <br /> ADDRESS ADDRESS CD O <br /> c < <br /> ............ p <br /> NE ' <br /> PHONE PHO <br /> DESCRIPTION o r <br /> o <br /> 4. Sanitary Facilities: '�• o <br /> 1. Work: 2. New Building Details No. Bathrooms '•....... .. . . <br /> New Building ` Type f Construction: No. Bedrooms ° <br /> ......... ' <br /> Addition �l2x C Septic Tank Size Gals. ..........�` <br /> .. <br /> Sanitary Size . Q.f.. ft. x ...s7'C?.'. ft. .......••. <br /> Filling .••....... Height..9........ Stories .......t...... 4a. Absorption Field Site: <br /> Moving .......... Area .......MOP........................... Soil Type .................................. . r <br /> Grading .......... Slope .......................................... 9 y ° <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... i <br /> Privy Dry Well _.......... home,garage, motel,etc.) <br /> Well ......... Trench .......... <br /> .�a 1.��... � Seepagep <br /> Subdivision Privy <br /> .......... . . <br /> Seepage Bed <br /> ----------------- <br /> -------------------------------------------- :U) <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road 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- I _a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING 0 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. O —^ <br /> 0 <br /> -------------------------------------- <br /> 5. Lot Size: p Fig. A. 6. Location: <br /> .C.o.�?..... ft. x ... v d.. ft. — o 0 D Q <br /> f�.... .................. sq.ft. ............................................................................... <br /> 5 dvc 1-r �-a r(c tCn <br /> I o <br /> + Cc 11 T <br /> ba vugt l �'• -'CD <br /> o <br /> z <br /> y, Lr)CD <br /> CA) T Cn oo <br /> CU <br /> < �• <br /> off y . < g m <br /> Z oo' fD <br /> o _° . �. <br /> o <br /> -, m <br /> CD <br /> ............... ..... .. . ...........G..-:�. -.. � - <br /> ature of Owner or Agent Date <br /> x 70 <br /> marks „ rn <br /> CD <br /> rfl <br /> .............................................................................................. .................. <br /> ... ....... ................................ <br /> .� <br /> �m <br /> pectionDate ....................................... - 1� 00000 � m <br /> 9............ ..... ......................... q4 000000m <br /> Zoning Admi strator T✓ 0 0 0 0 0 o cn <br /> TE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> ore 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 />