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Burnett County Office of Zoning Administrator o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> TO THE ZONINGyADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as ; :v <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 <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. a <br /> `\ :�0 <br /> vI1�............I.. l.............................. y <br /> h <br /> ............................................................. <br /> C. <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT a <br /> ,�A...../a3..:s................................................... ........................................................................... <br /> ......... ................. : . <br /> ADDRESS_ ADDRESSAA <br /> �X <br /> .......C....................................................... ......................................................................................... <br /> ADDRESS ADDRESS I4v <br /> 5..1..�..a..5........................................ ............................................................................... e <br /> ............. . . <br /> PHONE �•• •• <br /> 5�9 PHONE <br /> ..y.. .�.5................................................ <br /> PLUMBER WELL DRILLER <br /> ADDRESS ADDRESS CD � <br /> o <br /> < <br /> PHONE PHONE z o <br /> DESCRIPTION r <br /> 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms <br /> o <br /> 2. New Building Details •••••••••• � o <br /> New Building .......... Type of Construction: No. Bedrooms o <br /> co <br /> Addition Septic Tank Size Gals. <br /> .......... <br /> Sanitary .......... Size ft. x ft. ......••••.............. .............. . . . . <br /> Filling Height............. Stories ............... 4a. Absorption Field Site: <br /> e <br /> Moving .......... Area ........................................... Soil Type o <br /> Slope .......................................... , <br /> Grading o <br /> .......... X . : <br /> Mobile Home .•,.,..... 3. Use (describe exactly, Perc. Rate ...................................., 1 -family <br /> Privy y... home,garage, motel, etc.) Dry Well .......... �( <br /> Well Seepage Trench .......... GI <br /> ................................................... Privy p <br /> Subdivision y .......... <br /> ......... .................... <br /> a <br /> Seepage Bed <br /> -------------------- :\ <br /> -------------------------------------------------- p <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- a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING O < <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> ---------------------------------------------------------------------- <br /> 5. t Si e: ig. A. 6. Loc tion: <br /> s� v - ........� ? (tj GR ft. FR S l p 1 <br /> �.Y..... ft. x ... ......... ft. sq. ��`r-.........................1.[�.!t". f.s.................. (I <br /> r« <br /> N o <br /> O <br /> LM <br /> if M . <br /> r � <br /> -C <br /> ,l �T � Aj T `C <br /> bigT � Y t z <br /> o <br /> 2 S <br /> cc <br /> m <br /> �1 <br /> M Nr cnm2 <br /> C d CD <br /> N. NL , Q * <br /> 'd Ul < O•t7 <br /> 0 N V . : '< (a :E M <br /> Z 00 CD CD <br /> 6 0 7 �. <br /> j / / w CD m <br /> /G....... . ........ .. ... ........ .. ................ ....Y..(..?t..<... ........ ;\ o C <br /> Signature of Owner or Agent/e Date — <br /> X 70 <br /> Remarks ......................................................................... -n rn <br /> ............................................................................................... C O <br /> va <br /> Al 11 <br /> ........................................................................................................ ........ -Q <br /> InspectionDate ....................................... �? P. ... ............. .......�.�............ o 0 0 0 0 o m <br /> Zoning Admin' trator \: 0000000 <br /> OTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> efore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> its application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> ig until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> ith 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 />