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Burnett County Office of Zoning Administrator v CD 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 N o <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m e :OQ <br /> Ordinance, Sanitation Code,and with all oth pli le County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> T ) / -h �► <br /> ..........C......... .�.......r ................................................. <br /> v <br /> 0 <br /> OWNER easerrint) CONTRACTOR or SURVEYOR or AGENT a <br /> CD <br /> .. 4.........................ter........ ........ .r............................ ............................................................................................ <br /> ADDRESS ADDRESS <br /> ......................................................................... ADDRESS ................................................................... <br /> ADDRESS <br /> ........................................................................................... ............................................................................................ <br /> PHO E PHONE <br /> k ..p. ........................................................... <br /> n <br /> PLUMBER WELL DRILLER <br /> ADDRESS ADDRESS :(y a <br /> < <br /> ............ o' <br /> PHONE PHONE Z N r p�." <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° �3[� <br /> Bathrooms 1. Work: 2. New Building Details No. Bat •••�� � o <br /> New Building .......... Type of Construction: No. Bedrooms <br /> r CD <br /> Addition Septic Tank Size Gals. .......... '� <br /> .......... ................................................. <br /> Sanitary ... Size .............. ft. x .............. ft. <br /> Filling .......... Height............. Stories ............... 4a. Absorption Field Site: c i <br /> Moving .......... Area Soil Type .................................... C r c <br /> Grading ' <br /> Slope .......................................... �3 <br /> .......... <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Privy .......... home,garage, motel, etc.) Dry Well <br /> Well Seepage Trench ......... ,p <br /> ................................................... <br /> — Subdivision Priv y p \ <br /> ----------------------------------------- Seepage Bed------- ---- Cn <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- R <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING �.3 y• <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o' <br /> ------------------------ ----------------------------------- <br /> 5. Lot Size: Fig A. 6. Location: �► <br /> ................ ft. x ft. sq.ft. <br /> O +;.q1 <br /> CD <br /> o o <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> s <br /> _n o <br /> CD <br /> 0 <br /> 0 <br /> d <br /> co <br /> m <br /> rnr -V caZ� <br /> 0 s < c CD <br /> m. NQQ-< <br /> a v, < C . <br /> to y < to * rn <br /> Z oo `D fDM <br /> oLo <br /> 3 �. <br /> 0 <br /> CD <br /> R r7 - _ <br /> Signature of wner or Agent Date ° :k ' ' C <br /> �X <br /> , l..l.. r_. ..�r�...Remarks -n <br /> CD <br /> f '..l` .' CD <br /> to <br /> .................. c�. .. `/.��.9..9.............................................................. <br /> ................ ! -�!r..cC'. ............................................... <br /> gy <br /> , m <br /> Inspection Date��.. .--� ��,1 '1'v. .. ... ............ e 1 ............ 0 0 0 <br /> v g '' 0 <br /> Zonin Admi istrator <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 />