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Burnett County Office of Zoning Administrator o Z <br /> 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 3 <br /> w4, o O <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as H <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use c <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. a <br /> — m O <br /> G � .....f......... f..��, ................... ......: ................................................................ <br /> OWNER (please prat) CONTRACTOR or SURVEYOR or AGENT a v <br /> /� a (' <br /> ADDRESS �l C <br /> CD <br /> ..... 1..:=�L........ <br /> 5� 1... ......................................................................................... <br /> ADD ESS ADDRESS <br /> ...................................... <br /> •••PHONE <br /> PHONE \ <br /> , [ <br /> PLUMBER WELL DRILLER <br /> ADDRESS .DD..... .. <br /> R..E S................................................................................ <br /> A 0 ' <br /> S <br /> h o <br /> m <br /> .P...H.ONE....................................................................................... :� Z) <br /> PHONE <br /> r— <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details •••-/•' <br /> New Building .......... Type f Construction: No. Bedrooms - — f_ ? 0 <br /> Addition �.....••....•..�.......... Septic Tank Size Gals. <br /> Sanitary .......... Size ...../..�f.. ft. x .A�Z..... ft. .......... NA <br /> Filling .........• Height.... .zStories ...! 4a. Absorption Field Site: <br /> ........... . . <br /> Moving .......... Area , ' . .� Soil Type .................................... �� r <br /> G" o <br /> Grading Slope .......................................... � ,-• <br /> Mobile Home Perc. Rate ................................... <br /> ......... 3. Use (describe exactly, 1 family <br /> PrivyDry Well <br /> .. .. .... home,garage, motel, et��) <br /> Well .......... :5�':�; c'w�<1....�.C/ :�.:. Seepage Trench <br /> Subdivision „•„• Privy , <br /> .................................................... <br /> Seepage Bed .......... <br /> --- ---------------------------------------------------- ------- c <br /> Location proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig. A. Include road o <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. <br /> --------------------------------------------------- ------ <br /> 5. Lot Size: Fig. A. 6. Location, _ <br /> / ......................... <br /> t ..... ft. x .r U.n ft. — .... ..4? `t...... sq. ft. 1.-3.......:........../..v { <br /> o 7• <br /> IC <br /> v to t <br /> ailG, �s e/ <br /> r • <br /> M <br /> 4.1 <br /> Cn CnCD C CD <br /> Z <br /> oy:c : < ��� m <br /> Z oo <br /> o — <br /> :5,; 0 70 <br /> signature of Owner or gent ate — <br /> )r x <br /> �2tJUO�uen CQ� �/ % ................................................................... -n C <br /> iemarks ...................................................................................................... CD <br /> n <br /> ........................................................................................................., ......................... ...J.............................................. :.r <br /> p Q/M�o .IJA�t�q. 0 0 0 0 cr <br /> nsection Date ....................................... S......... .��.... 0666 0 <br /> Zoning Administrator's � 0 0 0 0 ,0 C <br /> OTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> More construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> is application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build <br /> g until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here <br /> th is found to exist. Changes in plans or specifications shall not be made without approval of the Zoning Adm inistrato, <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />