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r- <br /> OfficeBurnett County of Zoning Administrator o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 ; o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as y0.+ � <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land UseCD c ( _ <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. a "� <br /> 3 <br /> o <br /> .......................... ........... � 7 ..................................................... N <br /> Q <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT m m <br /> a <br /> P.,.o......... o.x....6•.7•................................................ ......................................................................................... <br /> ADDRESS ADDRESS <br /> � v <br /> 1 ..N..�a..t�..r.. .....1- .�5. .:................................. .....................:...................................................................... <br /> ADDRESS ADDRESS <br /> Lh <br /> PHONE PHONE <br /> .......... <br /> . <br /> PLUMBER W..ELL DRILLER <br /> A...DRESS...................................................................................... CDADDRESS D <br /> n O <br /> C? < <br /> ........... o <br /> PHONE PHONE z y <br /> DESCRIPTION 4. Sanitary Facilities: '�° o <br /> 1. Work: 2. New Building Details No. Bathrooms .......... <br /> o <br /> Rj <br /> New Building .•........ Type of C nstruction No. Bedrooms J ' Co <br /> v <br /> Co <br /> Addition �/ FY�.h/ ,q,� ,•• 0y" Septic Tank Size Gals. <br /> ... ..... ..... <br /> Sanitary •......... Size .............. ft. x .............. ft. ......•••• \ '•Filling .......... Height............. Stories ............... 4a. Absorption Field Site: (� <br /> Moving Soil Type .................................... <br /> ..... Area ........ �'. <br /> r— <br /> Slope ..........................................Grading .......... � _ ° <br /> Mobile Home .. ....•.. 3. Use (describe exactly, famil Perc. Rate ................................... <br /> Privy .......... home,garage, motel, etc.) Dry Well <br /> Well .......... .../.....0A.►'ri.E.l. 14-a-Al•� Seepage Trench ....... <br /> Subdivision „_,••.•• Y Privy .•••...... I <br /> ...........................,/...................... <br /> Seepage Bed .......... \A <br /> __ r <br /> Cn <br /> Location of proposed structures and existing structures,well,sewage systems,roads,etc.,should be sketched in Fig. A. Include road a- <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- CL <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING 1 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> O <br /> --------------------------------------------------------———----------- <br /> 5. Lot Size: i Fig. A. 6. Location: <br /> ft. x 7.. �r <br /> ft. —/ /0....... ......... s ft. °t. ��. ..1. ...l...s ..l............................... CD <br /> c <br /> J <br /> 0 <br /> N ct <br /> � O 0 <br /> YL <br /> N� <br /> -n <br /> z �. <br /> c m m c co <br /> NCL <br /> 0 'fl <br /> I m <br /> Ef , z oo' fD m 9 <br /> W o � <br /> .. .... .. • ..... ... ... .•�••.... h•••....... <br /> �'.3... Sr, : : p <br /> )ig a ure of Owner or Agent Date ° C <br /> iemarks ..... ....Fla.V.. .....�.t..f/...�. L!'e ��� ��J-�r �� � !►NE a -n m <br /> °�.�..............�.�. .!f..................... ........I... ..�.. ...........�Q�i.d co 0 <br /> m <br /> .... .. .... .. ... . .. .... ................. <br /> .... .�t�S..l..h �/ �?ttoning <br /> G� 6,'�{ :...�s1 �� ... . <br /> u <br /> ...... ...... ........ <br /> ............... 00000cN„ m <br /> nspection Date ....................................... . . ........ ................. <br /> Administrator 0 0 0 0 0 0 CA <br /> OTE: A preliminary site inspection must be made d nted on all structures involving sanitary facil es <br /> More construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attach d 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 Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />