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C7- <br /> Burnett County Office of Zoning Administrator v - -- 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT . <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < y <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m e <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. a <br /> . Sc 1.�. .. ............................. � ° <br /> O NER (please print) CONTRACTOR or SURVEYOR or AGENT a ;� <br /> .Q- .a.�... ... -................................ C ~� <br /> ADDRESS ` ` �z ADDRESS � v :V) <br /> .D�'LAW... ......1 ........�......................................... ............................................................................................ ' <br /> ADDRESS ADDRESS <br /> .... ..-.. ... ..1.. ......................................... <br /> PHONE PHONE <br /> ........... <br /> PLUMBER WELL DRILLER <br /> ADDRESS ADDRESS m <br /> _. < <br /> .................................................................................. ................................................... ....................................... o + <br /> PHONE PHONE z H <br /> r <br /> DESCRIPTION 4. Sanitary <br /> Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms .......... <br /> o <br /> New Building No. Bedrooms ` -0 <br /> Type of Construction: � <br /> Addition Septic Tank Size Gals. .......... <br /> ......... ................_................... .. .......... .. <br /> Sanitary .......... Size .Rb..... ft. x .ail...... ft. : <br /> Filling .......... Height............. Stories .....t......... 4a. Absorption Field Site: <br /> t <br /> Moving Soil Type .................................... o <br /> .......... Area ........................................... <br /> GradingSlope .......................................... <br /> Mobile Home •......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... I', <br /> Privy .......... home,garage, motel, etc.) �� Dry Well <br /> Well /l A� p Co MS�d,1C 1��h Seepage Trench .......... r <br /> ......... ..... ........ ...... ... .. <br /> Privy <br /> Subdivision .......... .. .1. S�.e.mt�!.�..� �`p .......... <br /> See d <br /> -------------------------------------------------- ---- — <br /> Cn <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc., should be sketched in Fig. A. Include road i s <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- fl <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 /> ---------------------------------------------------------------------- 3 <br /> 5. Lot Size: ` j CtC�S Fig. A.Y • <br /> ................ ft. x .............. ft. — ............................... sq.ft. <br /> Cn <br /> CD <br /> N O <br /> o c <br /> c <br /> CD <br /> s <br /> —,� <br /> ouee `S71 <br /> ��4.ea F?o�. l5ke o :V <br /> Kecvns KWt,os% . <br /> CD <br /> 1 <br /> M cnr cnCD <br /> co <br /> T. <br /> Sp' N Q Q•G ahi Q n' <br /> ID <br /> y � � rn; � •G cn � <br /> 0 A� % o o <br /> N <br /> O <br /> O rr <br /> � 7 7 C <br /> .......... ......�............................. ... o.......1 <br /> Signature of Owner o ent Date m X rr <br /> CD <br /> Remarks CD C <br /> ........................................................................................................................................................................................... <br /> ............................................................................................................................<.............................................................. En <br /> Inspection Date ....................................... ................................................................... 0 0 0 0 o R <br /> rr <br /> Zoning Administrator O O o 0 o U <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 />