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10 <br /> Burnett County Office of ZoFiing Administrator W 0 0 <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT . - 3 <br /> o <br /> TO THE ZO CIING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and'�ocated as N "" <br /> shown herein.-The undersigned agrees that all work shall be done in accordance syth the requirements of the Burnett County Land Use e, C [ '� <br /> Ordinance, San anon Code. and with all other pplicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 °- <br /> E l/ea/s/eyt <br /> G.�'ai �'e ... <br /> ...................... . .. ...................... . .......................................................................................... � <br /> OV�N �x IP Priry(1 <br /> b CONTRACTOR or SURVEYOR or AGENT a <br /> Q <br /> j(/y!) :. .................: ............................................... . .......................................................................................... <br /> ADDRESS ADDRESS m <br /> . ...... . . ............................................................................... <br /> ..... ..................................................................................... . . . <br /> ADDRESS ADDRESS <br /> ............................................................................................ �� L <br /> PH.... ..I .. ., ........................................ PHONE <br /> K(T . . . ..................................................................................... yC <br /> .. .. ... ........................................ .WELL DRILLER i fes. <br /> ............ <br /> .................................................................................... ................................................................. ............ <br /> ADDRESS ADDRESS 0 0 <br /> . ...................................................................... <br /> . . . ... . . .. . .. . .. . ................... O <br /> . ...... ..... . . . ....... .... ..... ............ ....... . ..... <br /> ,» <br /> PHONE � <br /> PHONE H <br /> .. ................ . <br /> DESCRIPTION 4. Sanitary Facilities: o <br /> v <br /> 1. Work: 2. New Building Details No. Bathrooms o :tn <br /> Type of Construction: No. Bedrooms .......•.. ° Q <br /> New Building .......... Septic Tank Size Gals. .......... <br /> Addition .......... .................................................... <br /> Sanitary ....✓..... Size .............. ft. x .............. ft. <br /> Filling iGrading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Area Soil Type .................................... ° <br /> .......... 0 <br /> MobileHome Slope .......................................... <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... EL. <br /> Dry Well J. <br /> Well .......... home,garage, motel, etc.) .... tom\ <br /> Seepage Trench .......... cCT <br /> Subdivision .......... .................................................... <br /> Privy .......... <br /> Camping Unit .......... .................................................... Seepage Bed <br /> ____ __________________________ _—_—_—__—_—_— i .N 9\ <br /> Location of proposed structures and existing structures,well, sewage systems, roads, etc., should be sketched in Fig- A. Include road i Q <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property Is located at a highway inter- <br /> section, show the Intersecting highways and the setbacks required along them and at the intersecnon- CLEARLY LABEL EXISTING <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. ° <br /> _ e ° 's <br /> _____ ______________ ___ --___----_—_--___—__---_—__—__— : 41 <br /> 5. Lot Size: Fig A. 6. Location: R <br /> ................ ft. x .............. ft. — ............................... s9. ft. .................................................................. . .. .. <br /> N <br /> m <br /> N a' <br /> t � r <br /> r— v : on <br /> 1 <br /> �) m <br /> Z <br /> O <br /> 7] <br /> l m <br /> (n r rp Z <br /> �' Nd C< d <br /> ° V < <br /> b <br /> M <br /> Zo o a 70 <br /> o � aro <br /> fA =� <br /> 0 <br /> 0 m <br /> G� m <br /> 1� p <br /> ...... .... ......... .. ..................................... ...................................... ° <br /> Sign ore f Owner r Agent Date X <br /> C aG T <br /> v <br /> Remarks ................................ <br /> ........................................................................................................................................................................................ <br /> v <br /> .................... .. . ................................... . <br /> ............. . .. .. ..... .... .. <br /> Inspection Date .. �.�. ....: ........................ . g o g 8 0 o f�/1 <br /> ....................................... <br /> Zoning Ad inistrator <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 />