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Burnett County Office of Zoning Administrator 3 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. <br /> 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 mI CD <br /> c <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> '+ W <br /> N h <br /> Gf. .�./............... G4 .C�.................................. ..W..... . ..ka.e.11'.....w� rr ✓�' ..t.. . c <br /> XCD <br /> OWNER (please print) CONTR OR or SURVEYOR or AGONT� CD <br /> Q v <br /> -- <br /> ADDRESS ADDRESS + <br /> ................. . . . . . . <br /> ADDRESS ADDRESS. . . iv <br /> ............ <br /> PHONE PHONE <br /> .W..E <br /> . ........D.RI............................................................................... :W <br /> PLUMBER LL LLER .� <br /> O <br /> ADDRESS ADDRESS m � <br /> t h O ' <br /> PHONE PHONE z y <br /> DESCRIPTION 4. Sanitary Facilities: ° 0 <br /> 1. Work: No. Bathrooms 0 <br /> 2. New Building Details •••••••••• � o <br /> New Building .......... Type of Construction: No. Bedrooms .......... L <br /> Addition Septic Tank Size Gals. .......... <br /> .................................................. <br /> Sanitary Size .............. ft. x .............. ft. .......... <br /> Filling Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Soil Type .................................... o <br /> .......... Area ........................................... <br /> GradingSlope .......................................... <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 /> Subdivision Privy i <br /> .(� .................................................... <br /> Seepage Bed .......... <br /> ---------------------------------------------------------------------- N <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- fl <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 /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... <br /> ^' N o <br /> \ l o <br /> Y O <br /> I I <br /> a <br /> 0 <br /> o <br /> ED <br /> CD <br /> m <br /> 1 <br /> c W � cd co <br /> co . � c m <br /> � <br /> L: � = hQ * <br /> �* o N N . G ffl g m <br /> 0D C T. M <br /> 6 4 5 <br /> 01�ao <br /> ........... -.. -.i�.3...... `�� c <br /> Signature of Owner or Agent Date 1 :�S -' <br /> X <br /> Remarks m <br /> ........................................................................................................................................................ .C'... . - <br /> ..........................................................................................................................................................................K.....� �1, v <br /> LTJ <br /> Inspection Date ....................................... . . 11 <br /> P P PP P P N <br /> Zoning Adminis rator K+ Oi` C o 0 0 0 0 o cn <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 />