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(-1 i C-„ ; ;./ . <br /> Burnett County Office of Zoning Administrator d - 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d' 3 <br /> O <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located ast,13� <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use c f\'Vf�\ VJ <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 fDa `i`` <br /> OWNER (PIe3 pr' t) ........................................ `. <br /> ........ .... . ....... ... ... ....... ..... . ....... .... <br /> C//O�Nf/TR//ACT�.�R or SURVEYOR r AGENT o. m <br /> .. . . . ................................................................................. 4:f/......1!�?:`..`..L�Y.....` �....3�y� �y`3............................ 'o. 9p ' <br /> ADDRESS <br /> DRESS <br /> R ESS S/•�/.../............................................................ :\ <br /> ADDRESS ”"'•' •'• <br /> ........................................................................................... <br /> PHONE . .......................................................................................... .�. <br /> PHONE <br /> ........................................................................................... ' <br /> . ......................................................................................... <br /> PLUMBER WELL DRILLER <br /> .............................................................................. ...... <br /> ............. . . . ..... O <br /> ADDRESS . .................................. ......... ........ .......... ............... m L1 <br /> ADDRESS <br /> n o <br /> ..................................................................... 0 < <br /> PHONE <br /> DESCRIPTION4. Sanitary Facilities: ° o <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details ••••••• <br /> New Building No. Bedrooms o <br /> Type of No. .......... <br /> f <br /> • <br /> Addition .......... .................................................... Septic Tank Size Gals. .......... < :�.H <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... Soil Type ............................I....... ; r <br /> o <br /> Mobile Home .......... Slope .......................................... .. <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... i <br /> Well „•,,,,,,, home,garage, motel, etc.) Dry Well .......... <br /> Subdivision .�.. Seepage Trench <br /> Camping Unit .......... .................................................... Privy <br /> .................................................... .......... <br /> Seepage Bed ......... <br /> _______ . <br /> 00 <br /> Location of proposed structures and existing structures, well, sewage systems, roads etc.,should be sketched in Fig A. Include road 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. <br /> —__---__—_ ------------------------------------------ _ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ft. x .............. ft. . ............................... sq. ft. ............................................................................... <br /> �l � <br /> -7� x <br /> C �J q4 IN <br /> o <br /> z <br /> �7 z <br /> d <br /> C <br /> w ' m m <br /> m � <br /> m 2. a = a m <br /> < C <br /> Z o i' 0 m <br /> D n <br /> o <br /> Signature of Owner or Agent Date <br /> X <br /> Remarks ......................................................................................................................................................................... m * m <br /> v <br /> ........................................................................................................................................................................................ fA <br /> ........................................................................................................ ...............................A........................................... <br /> Inspection Date ....................................... � .Go� 7AC !L >rJ : is <br /> uNi a o u�i o a m <br /> ZoningAd(ninistrator f $ 8 8 $ $ $ N <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary faCilitie5 <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 />