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Burnett County Office of Zoning Administrator 3 _ o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT �' 3. <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as H 0 <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m m V <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 n. V <br /> l y <br /> X..42//use...................... ....... . .............. CD <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT a <br /> ...................................... ................................................................................ a :a <br /> ADDRESS ADDRESS <br /> .. . rn. . .n.P... s's' ................ ........................................................................... = 7 . <br /> ADDRESS ADDRESS <br /> ................................................. <br /> PHONE PHONE . <br /> ................... ............. .................................................. ............................................................................................ <br /> PL ER WELL DRILLER <br /> . ...kk.r'?... ............................................. ........................................................................... <br /> ADD ESS ADDRESS <br /> o :> <br /> ............................................................................. ............................................................................... o' <br /> PHONE PHONE -_�Z :3 <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> No. Bathrooms <br /> 1. Work: 2. New Building Details o <br /> New Building „�... Type onstruction: No. Bedrooms ..�... m <br /> Addition ..........�t�hvA— Septic Tank Size Gals. .......... <br /> ..................... . <br /> Sanitary ..�.., Size�...�..�. ft. x ......�./. ft. <br /> Filling Height............. Stories .../......... <br /> 4a. Absorption Field Site: T' <br /> SoilType .................................... :' <br /> Moving .......... Area ............... . . ................ 0 <br /> Slope ................ '� ° <br /> Grading .......................... �+ <br /> Mobile Home .......... 3. Use (describe exactly, 1 ;f:a:mily Perc. Rate ................................... <br /> Privy home,gar fie, motel, Dry Well <br /> Well Seepage Trench .... ..... L <br /> .... ..... ................................ <br /> Subdivision <br /> .......... Privy <br /> ............................................... <br /> Seepage Bed 1. ..J.A � <br /> ---------------------------------------------------------------------- Cn <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road <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 < <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS.---------------------------------------------------------------------- <br /> i� <br /> 5. Lot Size: Fig. A. 6. Location: 5J <br /> ........... ft. x .............. ft. — ............................... sq.ft. <br /> Cy, 4 <br /> Cn <br /> 0 <br /> N <br /> :P.. e_7 <br /> <, 0 <br /> 41 <br /> f -n <br /> z ` <br /> sr 33t`•�' cn <br /> CD <br /> � Inm M � <br /> v1 o in < C <br /> o p CD m <br /> L d. <br /> 0 <br /> <Signature of Owner or gent Date — <br /> Remarks T <br /> �..y... 3 ...........: ............................................................................................ CD <br /> to <br /> .................... .. ..�/ ��! .'��'+�. , ...................................................................................... �1 •�� <br /> ........................ ...I. �.+�r.�.'F:!... —1 . ....... . .. ....... .............. ... ................ .......................... <br /> 01 <br /> Inspection Date ... .�.p ....'�. —�........ 4? ??L9... ...T.� J...................... 0 0 0 0 b o m <br /> Zoning Administrator 0 0 0 0 0 0 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 />