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Burnett County Office of Zoning Administrator D ' o 0 <br /> APPLICATION FOR SANI'rARY .— LAND USE — BUILDING PERMIT ' 3. . <br /> YTO THE 7PNiNG ADMINIV,RATOR:•The undersigned hereby makes application for a Permit for the work described and located as H <br /> _nown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m c <br /> rdinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 n.CL <br /> O <br /> 1. ,..rl Q7 <br /> ......... ..........c7... ..h- 1........................ ...... ............................. C <br /> m <br /> WN R (please print) CONTRACTOR or SURVEYOR or AGENT M <br /> CL <br /> - ............................................................................................ dW. <br /> -ADDRESS ADDRESS <br /> DDRESS............................................................................ ............,..........................,....,.....,...................................... f� <br /> ADDRESS <br /> t <br /> ............. .......T„ ..v........... ,y..7................. : m <br /> ,'HONE PHONE................................................................................ <br /> .. ....................................................................... ...................,.......,....................................................... <br /> ...,..... Yv <br /> LUMBER WELL DRILLER 'C <br /> o <br /> -ADDRESS ADDRESS M <br /> 0 0 <br /> n O o <br /> . .... ................................................................. ............................................ 0 <br /> ............................................ <br /> ; HONE .. <br /> PHONE <br /> DESCRIPTION o Z r- <br /> 4. Sanitary Facilities: ° ° <br /> I. Work: No. Bathrooms /V,o1.✓,Z 0� <br /> 2, New Building Details ` <br /> • o <br /> New Building .......... Type of Construction: No. Bedrooms .......... 'a f <br /> Addition �{/ ...... o ,�7 f.,K Mlf... Septic Tank Size Gals. <br /> /�► '� <br /> Sanitary Size ...�.Y..... ft. x ....1..Q... ft. <br /> Filling ......•... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving ...I...... Area ....;X.Sr ... ..'g.7. ........... Soil Type .................................... {,� 17- <br /> Grading Slope .......................................... ° <br /> Mobile Home Perc. Rate ................................... <br /> .......... 3. Use (describe exactly, 1 -family <br /> Privy .......... home,garage, motel, etc.) Dry Well .......... <br /> Well .......... P.o..R.C.fi....*...5 ro R/4,Gr b Seepage Trench <br /> Subdivision t p �` T- Privy �q <br /> F..!/.....f1IQ�E...� ......,Lt,Fr.......... .......... <br /> Seepage Bed ......... 'I< <br /> ----------------------------- $ --------------------------------------- to <br /> ucation of proposed structures and existing structures, well, sewage systems,roads,etc.,should be sketched in Fig. A. Include road <br /> %aback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- : <br /> :!ction, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> FRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. Q <br /> -----------—------------------------------------------ <br /> 6. Lot Size: Fig. A. 6. Location: N <br /> Oft. -I ........................................................................... ^" <br /> IV <br /> N <br /> �c O j <br /> ��p L <br /> 0 <br /> cAa + � <br /> Z <br /> d <br /> be <br /> M CW .1 cocoz <br /> CL <br /> -�l-�y s�° Z o o N M <br /> . <br /> O� 351 0 U1 S. <br /> o <br /> to <br /> *'.... .. ...................... 2 ........ <br /> Signature of Owner or Agent Date ° <br /> ;remarks ,•.•.,,.Increase..in..a�?praised valuation not to exceed 50% unless a x <br /> .......... <br /> cD <br /> .............. al..Permi,t...,s...okt ne� ....,......................................,..........................,.,,.. ............ �' -- <br /> p � '�-� i` <br /> ............... o o o 0 <br /> iris action Date ... ............. ..g.................... o 0 0 ' o 0 <br /> .............. .................... <br /> Zonin Administrator o 0 o g o <br /> ,OTE: A preliminary site inspection must be nldde dnd site approval granted on all structures involving sanitary facilities <br /> ?fore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> its application before a permit will be issued. Do not purchase or install a septic tank, do dny plumbing or start any build- <br /> ig until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> .ith 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 />