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Burnett County Office of Zoning Administrator T Z <br /> o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ' 3 0 <br /> ~ <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and loc ted as 'd2 ~ ;� <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Laid Use m c ;�_ <br /> Ordinance. Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> L)i <br /> ..:••••... .a. .. ......... ../.........,?,. �.��.� ../.�............ . ................................................................................ ......... m O <br /> OWNER (please print) e io <br /> j...N CONTRACTOR or SURVEYOR or AGENT <br /> ..5.......... 3....................5..6....x....................... .................................................................... :........ — <br /> ADDRESS '•""" " ' a <br /> ADDRESS v <br /> a..n!.............. .1... .. ...:................. :� <br /> ADDRESS ADDRESS <br /> 7...�.. '.-.3. .C...-. '6.. .°7..q........................... .................................................................................. ......... <br /> PHONE PHONE • / <br /> .............................. ............................................................ .................................................................................. ......... <br /> PLUMBER WELL DRILLER Sc/ <br /> ......... . ............................................................................... <br /> . ................................................................................ ......... O <br /> ADDRESS ADDRESS <br /> 'mG1 Q <br /> . . .................................................................... .PHON..E...................................................................... ......... 0 o <br /> PHONE <br /> DESCRIPTION o r <br /> 4. Sanitary Facilities: o ° <br /> 1. Work: 2. New Building Details No. Bathrooms ( '? <br /> CS.: o i <br /> New Building .......... Type of Construction: Na. Bedrooms -2 <br /> Septic Tank Size Gals. ......... i <br /> Addition ��..... ................................................. .. Sept •� <br /> Sanitary .......... Size ... ft. x ...A.Q.... ft. •••....,. <br /> FillinglGrading Height...l Stories ...../......... 4a, Absorption Field Site: <br /> MovingArea ........................................... Soil Type .............•............ ......... i r <br /> Mobile Home ... Slope ................................ ......... <br /> Privy .......... 3. Use (describe exactly, 1 •family Perc. Rate ......................... ......... <br /> Wen .......... home,garage, motel,etc.) Dry Well <br /> Subdivision ••••..•••. �'� Seepage Trench ......... <br /> Camping Unit Privy <br /> ------------------------- i h ctri-�- .f1 ..- Q� ....... QJ y <br /> ------- ---- ----- Seepage Bed------- :C <br /> Location of g — to <br /> proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig. A. inclu a road e <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highwa inter- a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXI TING 1 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. '^ <br /> ———— --------------- ------------------ <br /> --- O i <br /> 5. Lp/ttSi{e: .3 Fig. A. 6. Location: E <br /> . . ...., ft. x ..... .. ft. — sq. ft. .................................................................... .......... <br /> P" <br /> 01, <br /> N <br /> n <br /> M <br /> ° <br /> kAlJ <br /> _ Q <br /> ZD SV p <br /> v 'Ej <br /> En r <br /> 01 C <br /> .20 3o Z o o m m <br /> i ° <br /> C <br /> Ignature of Owner or Agent Date <br /> Remarks ....... ... ....... <br /> .... .. . <br /> . . <br /> S . el{... 1�-. ... . x ; O <br /> Q : ��gym;t ............................................. . ...... <br /> ...... . <br /> 'I <br /> Inspection Date ....................................... ....... . .. m <br /> .. . . ................: i .�.: . . . ..... Uii; o � m <br /> Zoning Admini ator $ $ $ $ $ y <br /> faciliti <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary es <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached es <br /> any plumbing or start any build <br /> this application before a permit will be issued. Do not purchase or install a septic tank, do to <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 tie made without approval oft e Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />