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Burnett County Office of Zoning Administrator o 0 <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 y <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use CD e V <br /> Ordinance, Sanitation Code,and with all other applic a <br /> le County Ordinances and the laws and regulations of the State of Wisconsin. 3 �13 <br /> r (D <br /> Q • <br /> ��p <br /> /�e s...........................................7 1 l <br /> ...... ... .... . . <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT CD M <br /> lye..W...../�Tc.t'.. .71 f1.7.t. .....!![f.rf'!.L.. .�.'h..17.. ar'/?. ...... !i�l..S................................ cp <br /> ADDRESS ADDRESS �•+ V <br /> m <br /> ..S.r. ..r..,l��. :.. . ....�.........L .�.. ....2.9..r. <br /> ADDRESS ADDRESS <br /> ........................................................................................... . .... ................................................................ . . <br /> PHONE PH....O...NE....... O� <br /> ......................................................................... .................................................................. W <br /> PLUMBER WELL DRILLER <br /> ............... <br /> ........................................................................................... ..A.....RES"E'*S.S............................................................... _. <br /> ADDRESS DD 0 0 <br /> 0 o <br /> r. < <br /> . . . ..... ............. . <br /> PHONE PHONE z �, r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms o ?� <br /> New Building .. Typ�ef°f Construction: No. BedroomsCD <br /> Addition .......... ... ... ... Septic Tank Size Gals. <br /> Sanitary Size ..... .r.. .. ft. x .......3...G.. ft. .......... <br /> Filling .......... Height . Stories ....�......... 4a. Absorption Field Site: ' <br /> ,� tf Soil Type .................................... o <br /> MovingArea ......... ................................ <br /> GradingSlope ... ..................................... �+ <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Privy hom garage, motel, etc.) Dry Well <br /> Seepage Trench .......... <br /> Well .......... c <br /> ....................... Privy <br /> Subdivision .......... """"" <br /> .................................................... . . <br /> Seepage Bed <br /> ---------------------------------------------------------------------- <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 /> 6 <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 y <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o p <br /> ----'------------------------------ ----------------------------------- <br /> 5. Lot Size: Fig A. 6. Location: U" <br /> ..................... s ft. x ..... 0 a ft. — .......... ft. <br /> q. <br /> o 0 <br /> rF <br /> • V <br /> � T 1 <br /> m <br /> O <br /> PI , <br /> CD <br /> CD <br /> cn cncoZ� <br /> c m CD <br /> d <br /> cD > C <br /> G l m• N Q a < - ; i1 <br /> < C : 5' <br /> oH � m <br /> Z o o' fD CD 70 <br /> ° <br /> °Qo "f <br /> S atur o Owner or Age nt ate C <br /> n <br /> X <br /> RemarksCD y.............................................................................................. - m <br /> ........................................................................................................................................................................................ <br /> ....................................................................................................... . ......................... .......................................... o o 'n <br /> O; <br /> p ooE; Ni <br /> InspectionDate ....................................... ../........ .... .. .. .....` J................ i o 0 0 0 0 CD <br /> Zoning Adm{ istrator o 00 00 o fn <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 />