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V'l 0�, <br /> Burnett County z Office of Zoning Administrator W CD 0 0 <br /> APPLICATION FOR SANITARY —LAND USE — BUILDING PERMIT ; D :\ <br /> O <br /> TO THE ZONING ADMINISTRATOR* The undersigned hereby makes application for a Permit for the work described and located as y -^ :V <br /> shown ;erein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a. <br /> ...................................................... N CD <br /> Q,E!v/I..�.......�i l�1...?r s4..�i................................. ................................... o <br /> a <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENTCD <br /> CD <br /> Ff �f... ............................................................... <br /> ADDRESS ADDRESS m t <br /> asIJ <br /> .......................................................................... .ADDRES......—E'S"S... mz <br /> ........................................................................... :� <br /> ADDRESS <br /> �1 �D <br /> ................................................................................. �1 <br /> PH/ONE . PHONE ;� <br /> ........................................................................ iaW <br /> PLUMBER WELL DRILLER <br /> 0 <br /> ADDRESS ADDRESS :(.- a o y <br /> PHONE PHONE Z a r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> No. Bathrooms i <br /> 1. Work: 2. New Building Details "' ' "" o <br /> No. Bedrooms rs� D.... <br /> New Building <br /> .,,,,,,... Type of Construction: e�pi �i <br /> Addition <br /> Sanitary ... Size .............. ft. x .............. ft. .20,00 <br /> i <br /> Filling .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Soil Type ` r <br /> .................................... O <br /> GradingSlope .......................................... <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Privy .......... home,garage, motel, etc.) Dry Well <br /> Well . Seepage Trench .......... <br /> ........ <br /> Subdivision Privy <br /> .......... .................................................... <br /> Seepage Bed .......... <br /> ---------------------------------------------------------------------- <br /> Location of proposed structures and existing structures,well, sewage systems,roads,etc.,should be sketched in Fig. A. Include road 6 <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- o- <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. o <br /> ---------------------------------- ----------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... <br /> Cn <br /> CD <br /> 0 <br /> h <br /> N o <br /> O 3 <br /> cn (� <br /> 0 <br /> � / N <br /> _n :W <br /> Z <br /> o <br /> c; <br /> �o Cn Cn co Z <br /> m c n: �. 3 c cD <br /> m. Naa< — '+ a � <br /> °' 0 � <br /> -a cn <,C: ' <br /> � � C <br /> Q V; V . : •G (M C m <br /> Z o O fD T. <br /> o : <br /> 5LQ <br /> _ <br /> -h ............. ...................................... <br /> Signature of Owner or Agent Date <br /> Remarks ..TElnIk.,Uen� T� C'las�. ...�` `"'QOW.'..rt........................ we.1�-a p•.ocre o'15 ......�•.....(.-- C m <br /> .....................................�....................... x M <br /> to <br /> .... �......... . .:. ................................................................................................................................................ <br /> ........................................................................................................................................................................................ : e: <br /> cNNn M: \ : o0o m <br /> Inspection Date ....................................... 4P..17 .......... ...................... o 0 0' o rn <br /> Zoning Ad nistrato�� <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary fac ties <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> this application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> with 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 />