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Burnett County Office of Zoning Administrator 3 CD o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT �' d <br /> TO THE.70NING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as H 4 <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use CD c <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3CD <br /> CD <br /> N r•h h. n G <br /> WNER (ple e print) CONTRACTOR or SURVEYOR or AGENT a 7 <br /> .. 12...............................^ ................................... ............................................................................................ <br /> 'DRESS/ ADDRESS r+ <br /> �a-lvbu .. 1,��... 51`/ Q........... ........................................................................... -. . . .... .. . ........ . . . <br /> AA1)DRESS R6b 8�5/e2� ADDRESS <br /> V ^ C <br /> .?..5�.............. ti <br /> PHONE PHONE <br /> - .. .. ................................................................... o <br /> PLUMBER WELL DRILLER 3 :w <br /> ............................................. .A.....DDRES........ .............................................................................. <br /> ADDRESS S T� CD <br /> `1 iUv ,n+ o C <br /> ...............:.....:................. 0' <br /> PHONE PHONE � z H _� <br /> DESCRIPTION 4. SanitaryFacilities ° o <br /> 1. Work: No. Bathrooms ..... i <br /> 2. New Building Details ; o <br /> New Building Type of Construction: No. Bedrooms > ... l a <br /> Addition ............................................. <br /> Septic Tank Size Gals. ........ <br /> Sanitary .... Size .............. ft. x .............. ft. •........ <br /> o t ?O <br /> Filling ...•...... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving <br /> Soil Type <br /> • r— <br /> o <br /> Grading Slope .......................................... o <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family <br /> Perc. Rate ................................... W <br /> Privy .......... home,garage,motel,etc.) Dry Well <br /> Well Seepage Trench .......... c <br /> .................................................... ivy ......••••Subdivision Pr c <br /> .......... <br /> .................................................... . . <br /> Seepage Bed .......... `i"1 :C <br /> ---------------------------------------------------------------------- „n N <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road c <br /> 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- 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. H <br /> o <br /> ------------- <br /> 5. Lot Size: � �e �$� Fi A. 6. Location: i _� <br /> 1. <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... <br /> m <br /> • h <br /> o ?� <br /> �• :ate: _ <br /> 0 <br /> 0 <br /> c <br /> Cn z <br /> Co c m c m <br /> m NQa�< — <br /> a i7t < <br /> Z o o `D <br /> o �� 5 <br /> T '� m <br /> CD <br /> ... . ....................................... ......�....�......�....... <br /> A <br /> Signatu a of ��wner Agent Date C <br /> X 70 <br /> Remarks . .. ..... ......... .. 5 .. ................................................. CD C <br /> m <br /> CD <br /> ...................... ... . . . ................:......:`..' .................................................................................................. <br /> .... .. �Al <br /> 0000oL mInspection Date .C::.... r!.1.................... ................... ................................ � m <br /> Zonin nlstrator o 0 0 0 0 o Cn <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <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 />