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f"yl, �✓ ;li , <br /> Burnett County Office of Zoning Administrator g o o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 _ \ <br /> o <br /> sh THE ZONING ADMINISTRATOR The undersigned hereby makes application for a equine for the work described and located Use <br /> c .� <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett Count Land Use m as <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> .......................................................... <br /> .5 .................................... <br /> 0 <br /> OWN R (please print) NTRACTOR or SURV EVOR or AGENT a <br /> m � � <br /> !u.. .a. ... ...s..6..U.................................... ................................................................................. <br /> AD RESS <br /> ADDRESS <br /> ur .. ..1!/ ...... :..`c' .................................. <br /> ............................................................................ <br /> ADDRESS ADDRESS <br /> 3y9-.aZ.9a.. ......................................................... . .......................................................................................... <br /> PHONE PHONE <br /> ............................................................ . .......................................................................................... <br /> PWMBER WELL DRILLER [ <br /> O <br /> ADUR <br /> .............. <br /> ESS............................................................................ .ADDRESS.............................................................. °, o <br /> .............. o <br /> ........................................................................................... . ............................................................................ .; <br /> PHONE PHONE Z r :t <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> v :W <br /> 1. Work: 2. New Building Details No. Bathrooms .......... la .� <br /> New Building .......... Type of Construction: No. Bedrooms .......... <br /> Addition .................................................... Septic Tank Size Gals. .......... <br /> .......... <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Area ........................................... Soil Type .................................. <br /> .. r <br /> o <br /> Mobile Home .......... Slope .......................................... .+ <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Well ,......... home,garage, motel, etc.) Dry Well .......... <br /> ,t/„ Seepage Trench .......... <br /> Subdivision <br /> .......................................I............ Privy <br /> Camping Unit <br /> Seepage Bed .......... : <br /> ---------------------------------------------------------------------- <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- <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. o <br /> ________________________ ___ _________ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... <br /> J 2cJ o o. <br /> s0 a <br /> i 1 <br /> CO.53 <br /> 0 <br /> ,)I ':A% <br /> `7 <br /> ti„ T :V4 <br /> ' C <br /> z <br /> 0 <br /> a <br /> - m <br /> :ary Nr0 W Z <br /> c �v � <br /> oN. M mam <br /> Z 0o n <br /> 0 0 aro <br /> EA 0 _ <br /> 0 �O <br /> Signature of Owner or Agent Date <br /> X <br /> Remarks ......................................................................................................................................................................... Lo : m <br /> �o <br /> ...................................................................................................................................... ...... . <br /> C T <br /> m <br /> Inspection Date ....................................... in..2?.?:L ... ... ... .... ..... �✓............ i >r u o u, o u, <br /> Zoning Adminis r �` 8 8 8 8 8 8 rm/� <br /> NOTE. A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilitwS <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 lie made without approval of the Zoning Administratol. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />