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Burnett County Office of Zoning Administrator 0) CD 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT • <br /> o <br /> TO TAE ZONIAG ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as N <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use co e <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> J) <br /> o '� 4?.1...... ...�.1.... .!� .... ............................................................................................ ? <br /> OWNER (please print) f CONTRACTOR or SURVEYOR or AGENT a CD <br /> d� <br /> ................. . <br /> ADDRESS ADDRESS �* <br /> \..�.h.�.a.E'...... 3. V. ....... ..M!1:............... .. .......................................................................................... :� <br /> ADDRESS ADDRESS c <br /> '.�..�.'... .....y.. ........ S` (.......... t. <br /> PHONE PHONE <br /> D..R.....LL...ER....................................................................... <br /> PLUMBER WELL I <br /> ............ .............................................................................. <br /> ADDRESS ADDRES..S 0 <br /> ......................�.��.�.......1r�J...�.�/).... xf.4.r��} o 1 1 <br /> PHONE PHONE i � �I z r 'N <br /> DESCRIPTION 4. Sanitary Facilities: f ° o ° <br /> Bathrooms <br /> 1. Work: �( 2. New Building Details No. <br /> New Building (.:.... Type of Construction: No. Bedrooms .. ..... <br /> Addition P`u Septic Tank Size Gals. ........ . <br /> ......... ..........�......^... . <br /> Sanitary �.... Size ....3.` ... ft. x ...3 . ft. <br /> Filling .•........ Height............. Stories ............... 4a. Absorption Field Site: <br /> Soil Type .......... `?.............. : r i <br /> Moving .......... Area ........................................... r o <br /> Grading .......... _ Slope .................. ....................... 3 h <br /> Mobile Home .......... 3. Use (describe exact) , 1 -family Perc. Rate ................................... , .a <br /> Privy .......... home,garage, motel, <br /> Dry Well .......... 1 <br /> Seepage Trench <br /> Well I <br /> .... .................................................... >s <br /> Subdivision Privy <br /> Seepage Bed / YAK3, <br /> ------------------------------------------------------------- <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc., should be sketched in Fig. A. Include road + "� <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- e <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 0 <br /> ----------- o <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... CD <br /> o � Cn <br /> CD <br /> 0 o. <br /> O 7 <br /> O � <br /> N � <br /> N : <br /> r-F <br /> 0 <br /> V C<7 <br /> Z11 <br /> z <br /> 0 <br /> CD <br /> C C r qM <br /> CDc c) �. CDm. N Q Q-0 cr < � : OM <br /> < m <br /> z oofD `D � <br /> o c � <br /> � 5 _ <br /> :v o <br /> o 70 <br /> J� <br /> .............. o C <br /> Signature of Own or Agent Date — <br /> Remark .... .. .. . . .........�... ...............'v. � .�.�1� 7..................... CD <br /> ...................:�� U ......................................- yr <br /> Ln <br /> Inspection Date .... ... .: ... .g �..``.......g...... . . . ....' .............. 0 0 0' o o m <br /> Zonin Adm�ra 000 oo (n <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 />