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Burnett County Office of Zoning Administrator -� z <br /> CD 0 o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT '• 3 3 �„ <br /> d <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < 7 0 Q <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m c :v <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 0- O, <br /> a) <br /> a, <br /> OWNER (pleas /�/ <br /> print) �* """"••• ••• m ' <br /> ON R TOR or SURVEYOR or AGENT. m m <br /> CL <br /> ADDRESS ADDRESS <br /> r+ <br /> ..a. .e.F...... ....................................................................... <br /> D ADRESS .......ADDRESS V O <br /> PHON ....J,� .r PHONE............... .� <br /> . .1.............................................. <br /> .................. to...-...�,s".r�', ................................... <br /> PLUMBER WELL DRILLER ^� <br /> ............................................................................ <br /> ADDRESS ••••••••••••• � � �I <br /> ADDRESS <br /> h <br /> o coo <br /> PHONE PHONE � <br /> y <br /> DESCRIPTION z r- <br /> 4. Sanitary Facilities: 0 ° ° <br /> 1. Work: No. Bathrooms 2. New Building Details .......... <br /> New Building Type of Construction: No. Bedrooms .......... <br /> Addition Septic Tank Size Gals. <br /> .......... ......................... <br /> Sanitary : <br /> ......... Size .............. ft. x .............. ft. .......... , <br /> Filling .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> MovingArea ........................................... Soil Type .................................... <br /> Grading Slope .......................................... <br /> Mobile Home 3. Use (describe exactly, 1 family Perc. Rate ................................... <br /> Privy home,garage, motel, etc.) Dry Well ` d <br /> Well Seepage <br /> Trench .......... INc , <br /> .................................................... C� <br /> u division .......... Privy •„......• <br /> -————————————————————————————————————— Seepage Bed ......... .0 <br /> _ocation of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road 9 C7 <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- Q <br /> ection, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING < <br /> 'TRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> c ° <br /> i. Lot Size: Fig. A. 6. Location: <br /> '�. �.. ft. x ..Ii.i.. ft. — <br /> sq.ft. ..A.O.r..Y... .. 4..I..n. .'..�.. l E................. <br /> La kr CD <br /> _0 <br /> N O <br /> o <br /> V e <br /> -0 <br /> � La <br /> rr <br /> �L'Illo J a <br /> r - co co <br /> <. " _ = <br /> Q�S Naas — o <br /> Z b UK m <br /> ITI <br /> ID <br /> 3..... . ...... ..... ... ... ........L �e,7.. a <br /> ature onn``wner or Agent Date �� / ° C <br /> emarks ."9teq.....G�l,Vu Via../..5...�`° 62 SeeQ�P „�../ ' �' <br /> X <br /> ............................................................ <br /> -n m <br /> CD <br /> ,.... � ......� .. frees iiv 3.s'St� o Leis n. `° v <br /> . �. ..............................4. 7. .......... 1................T.��..... ............... 6 <br /> IA�l ° 7` 4P/d°73�' <br /> o . <br /> if <br /> ispection Date .(Y g� 1a: <br /> '(..�........................ i,0000cr" m <br /> . ............ ......................................... . . . . . . <br /> Zoning'Administrator 0 0 0 0 0 Cn <br /> )TE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> fore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached 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 /> I 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 />