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Burnett County' Office of Zoning Administrator C z <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT <br /> °' �: ), <br /> TO THE ONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < , 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 c <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> [1.. �.) O <br /> .... ..........................I. .......................................... H r•h <br /> OWNER (please print) H <br /> 3 CONTRACTOR or SURVEYOR or AGENT m <br /> 6 r ov. . <br /> L <br /> CD <br /> .............. ............................................................................................ADDRESS QC <br /> G <br /> h <br /> .7 4 I' <br /> ADDRESS e <br /> ........................................................................................... .................................................................PHAE QQI �O <br /> �r PHONE <br /> pO <br /> PLUMBER ......................................................................................... �� <br /> WELL DRILLER <br /> ADDRESS ...................................................................................... sue, <br /> AD...DRESS ; CD <br /> n O <br /> PHONE PHONE <br /> DESCRIPTION z H r <br /> 4. Sanitary Facilities: ° o 0 <br /> 1. Work: 2. New Building Details No. Bathrooms / <br /> New Building .•„ ,•, Type of onstruction: No. Bedrooms .•,�-,• -°6 <br /> Addition ID <br /> ,•,,,K. •„••.,•„ h C ww '� Septic Tank Size Gals.. . ............ ...... . . : <br /> ... .. ...... .. . <br /> Sanitary ; <br /> ...��.. Size ... ... ft. x .... ...... ft. <br /> Filling „•••... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Area Soil Type .................................... <br /> Grading Slope ........................... Y....... '+ <br /> Mobile Home 3. Use (describe exact) -famil Perc. Rate ............�.a�................. <br /> N <br /> Privy .... home,garage,motel,etc.) Dry Well <br /> Well •• . ... Seepage Trench T <br /> Subdivision ............................................. <br /> 0 Privy <br /> ------------------------------------ Seepage Bed 3•fo <br /> Location of proposed structures and existing structures,well, sewage systems, roads etc., should be sketched in Fig. A. Include road ...i C <br /> c <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 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. H <br /> :4% j• <br /> 5. Lot.Size- Fig. A. 6. Location: :2` i <br /> ./Ao..... ft. x . Q�... ft. — D-1 b m <br /> N <br /> T, <br /> 0 <br /> CD <br /> z <br /> r <br /> o <br /> cc <br /> r <br /> m <br /> qc mAQe. <br /> 5 <br /> Z O O fD <br /> o � T. <br /> 01 <br /> � O 0 70 <br /> ...�of <br /> ... ....... ° m <br /> )nature0 er or Agent Date ° C <br /> :mark CD ; m <br /> CD <br /> v <br /> .................................................................................................................................................................................... <br /> ............................^..........^............................................................. <br /> .............. <br /> spection Date f J e o 0 0 0 o v m <br /> ....y ............................... 000000 <br /> Zoning Administrator �: 0000000 <br /> TE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> ore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> h 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 />