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cr) H //Burnett County Office of Zoning Administrator d C o o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT o 2. o • <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as -- y -h <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use co c <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. a <br /> a <br /> !. .--R <br /> CP 14 Jet q cie Ma kl y o <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT o fD <br /> iC) <br /> ADDRESS N, ADDRESS m <br /> A[ D� IV' Sr — a <br /> RESS �� ADDRESS .'-'' - <br /> �(2 / 'f..3S— ' �- <br /> PHONE PHONE ,O <br /> 1_ N <br /> PLUMBER WELL DRILLER <br /> 0 <br /> ADDRESS ADDRESS -• <br /> r 6-) <br /> o. r» <br /> PHONE PHONE Z y r <br /> DESCRIPTION 4. Sanitary Facilities: 0 o 0 <br /> 1. Work: 2. New Building Details No. Bathrooms <br /> New Building A" Type oCownstruction: No. Bedrooms CD <br /> Addition �P�Qe Septic Tank Size Gals. v <br /> Sanitary Size ..Z-0 (ft. . Q ft. � .- <br /> Filling Height V x Stories .../ 4a. Absorption Field Site: <br /> Moving Area (Q O o - Soil Type r- <br /> Slope 0 <br /> Grading o <br /> Mobile Home 3. Use (describe exactly, 1 -family Perc. Rate <br /> Privy home,garage, motel, etc.) Dry Well <br /> Well Seepage Trench tj <br /> Subdivision Privy <br /> Seepage Bed r <br /> Location of proposed structures and existing structures,well, sewage systems, roads,etc., should be sketched in Fig. A. Include road CA/0_ 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. o. <br /> 5. Lot Size: Fig. A. 6. Location: bO <br /> ft. x ft. — sq.ft. <br /> c. <br /> vs <br /> CD <br /> C) <br /> N o' <br /> o a <br /> C. Al <br /> 0 <br /> CA) <br /> 0 <br /> � W� <br /> a <br /> CO', LP I z <br /> Z <br /> I <br /> ‘.1 <br /> o° <br /> Nr � � Z <br /> r= � d = <br /> — o - <br /> m N Q Q< — ri _0_ <br /> -O cn Z. °� 171 <br /> eV e <br /> by. c m <br /> / o oo fD —_ 73 <br /> Tg <br /> cn cn .. 14N. b <br /> A1—f(-Q ga—a,c4....-t— 77( r.? - o Ti <br /> Signat e of Owner or Agent ate '* <br /> X 7: <br /> Remarks co C <br /> 0 u <br /> o <br /> Inspection Date a b b b b b b IT <br /> Zoning Administrator o0000oU <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 he made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />