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Burnett County Office of Zoning Administrator 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. 0 y <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < -" '� <br /> c <br /> shown herein. The undersigned agrees that all work shall be done In accordance with the requirements ti the Burnett County Land Use 3 0_ <br /> ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wi5Con5in. — Cu O <br /> i5D �F-SOE 4 <br /> ........................................................................................... CONTRACTOR or SURVEYOR or AGENT •/ ' ..0 <br /> OWNER (p ase print) <br /> �R2/(l1 y .^.1......................... . .......................................................................................... <br /> . ..> .......—...... ........... . F ADDRESS ftp <br /> ............... . I <br /> ADIlD{R/ES'`L� F ... .....'S„�V.�� ............ <br /> .......... . <br /> ADDRESS <br /> S : <br /> V <br /> ADDRESS 1� <br /> ;( <br /> ........................................................................................... PHONE <br /> PHONE <br /> p /C I p ......................................................................................... <br /> ..... ...`.`is..........1 �. .. .` .................................... 'WELL DRILLER , <br /> PLUMBER <br /> O ` <br /> u..� r ............................:.... .................................................... <br /> ......................................................... .ADDRESS `m <br /> ADDRESS - <br /> ................................................................................ .. o <br /> o < <br /> SJ . . .C ....D................................................ <br /> PHONE <br /> PHONE � O :� <br /> DESCRIPTION 4. Sanitary Facilities: <br /> 1. Work: 2. New Building Details No. Bathrooms .. <br /> ^v o <br /> No. Bedrooms ..� � <br /> ........ <br /> New Building .......... Type of Construction: Septic Tank Si3,a Gals. 3 <br /> Addition ...... ... .................................................... F--( .. 77 P&K: <br /> Sanitary .. ... Size .............. ft. x .............. ft. 4a. Absorption Field Site: -� <br /> Filling/Grading Height............. Stories ............. . l Fr i <br /> Soil Type t <br /> ....................Area ....................... <br /> MovingSlope ........ . . .0........ . ... ...... ^ , <br /> o.. <br /> Mobile Home Perc. Rate ................................... <br /> 3describe exact) -family <br /> Privy Dry Well <br /> Well hom garage, motel, etc.) Seepage Trench ' <br /> Subdivision .......... .................................................... Privy .......... LQ i <br /> Camping Unit .......I.................. Y <br /> Seepage Bed---------- t� <br /> --------- <br /> a <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 lO <. <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEAR LV LABEL EXISTING 0 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. �� <br /> --------- <br /> 5. Lot Size: <br /> Fig. A. 6. Location: E <br /> .n <br /> sq.ft. ............................................................................... 'l <br /> N <br /> N <br /> ^. <br /> N O <br /> O � <br /> o <br /> 3 � 1 <br /> S <br /> T <br /> t <br /> i <br /> �_ <br /> EAa n , _ _ ' F <br /> 'o ai < C m <br /> g : am <br /> 2 0o <br /> 0 0 nm � <br /> 0 <br /> 'moo � <br /> (yam— rr <br /> �so d 0 C <br /> 'J <br /> ...................................... <br /> ... ........................ .............. Date <br /> Signature of Owner or Agent X R <br /> m <br /> m <br /> Remarks .................................................................................................................................................. .................. <br /> . .... � , <br /> ........................................................................................................................................................................................ <br /> Fn ' <br /> ..........I...... ....................................9". <br /> ........... :. ............ �,Ins ection Date . rr <br /> �C✓p ...................................... ' • C <br /> Zoning Administrator ' <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 />