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Burnett County Office of Zoning Administrator v _ 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 < y :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. I a <br /> '1 a <br /> O <br /> /4LVJ ..... <br /> .... JV c3��mtR y <br /> ................. .......................R u�. ....................... ......................................................................................... CD <br /> OWNER (please print) <br /> CONTRACTOR or SURVEYOR or AGENT coo _ ?(/) CDryl a <br /> 1� <br /> /<-19 <br /> ys....... .............................................. ............ <br /> ADDRESS <br /> A ........................................................... <br /> DDRESS w <br /> CD <br /> .C.r!ykc 4. -,(a,JE m�uN s`s �..9........ <br /> �............................ ............................................................................ <br /> ADDRESS ADDRESS `(U <br /> G12 — qLS"- E3 9. .................................... ......................................................................................... <br /> PHONE PHONE <br /> .......... <br /> PLUMBER WELL DRILLER <br /> ADDRESS ADDRESS <br /> m G) <br /> rt o <br /> ............ —' <br /> : <br /> PHONE PHON. E Z 3 h <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms - : <br /> New Building f No. Bedrooms ° <br /> Type°J41QsryGtion: ° :.� <br /> Addition ..,,,rr,,,,, „ Septic Tank Size Gals. .......... `• <br /> .. <br /> SanitarySize ... sa�.5v... ft.o�.�y... ft. x ... <br /> Filling .......... Height... ....... Stories ... ........... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... Soil Type .................................... r Grading .......... Slope .......................................... <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Privy .......... home,garage, motel, etc.) Dry Well .......... <br /> Well .......... 6 Seepage Trench ........ <br /> .............. <br /> Subdivision .......... Privy .......... <br /> .................................................... <br /> -------------------------------------------------- Seepage Bed ......... <br /> cn <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- Q <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. 0 a <br /> -------------------------------------- <br /> -------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: 0 <br /> I.�..... ft. x X...... ft. — ............................... sq.ft. ............................................................................... <br /> �J�K PSEi i <br /> N 0 3. <br /> v 'W <br /> act) <br /> N <br /> �Q` -n <br /> ,yc,, �0,- co JC Li N ff ° <br /> CD <br /> Cn <br /> Z <br /> CD <br /> �h•Q � <br /> CD <br /> cn < C, <br /> /X Z oo'm M m <br /> co <br /> •PAX <br /> ° <br /> AGO S. <br /> i� <br /> ;p 0 <br /> ....... �'. .� 3 'w C) <br /> ...... ..... ..... v : : : : : : <br /> Signature of Owner or Agent Date o c_ <br /> X 7� <br /> Remarks -n c ; m <br /> v <br /> e: <br /> CD <br /> GO <br /> 00000cnm <br /> Inspection Date ....................................... �instQ..l...,... .. . .......... .........x.j..................... 0 0 00 0 0 m <br /> Zoning Administrator 0000000 <br /> DOTE: 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 /> his 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 /> iith 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 />