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Burnett County Office of Zoning Administrator 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as <br /> n <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use 0 e ? v <br /> Ordinance, Sanitation Code, and with all other aJpplicable County Ordinances and the laws and regulations of the State of Wisconsin. <br /> � .DSS........ Q.n.I.4. ........�1 l..0..A.i ............. ............................................................................................ H o <br /> OWN (please print) CONTRACTOR or SURVEYOR or AGENT 0 <br /> .W..a...... ai �.�... ...T................................ ................................................................................ ........... d h. <br /> ADDRESS ADDRESS <br /> ...5 ......PG ............m..�............. co a .......................................................................................... <br /> ADDRESS ADDRESS <br /> .4 <br /> •O ih <br /> yI. . <br /> �. ...................... ........................................................ . ................................................................................ <br /> PHOPHONE <br /> PLUMBER WELL DRILLER �Q <br /> /S <br /> .................................. <br /> 5... <br /> ........................................................................... ....AD...D. .RES.................................. ... .... c1 <br /> ADDRESS S <br /> n O <br /> O........................................................................................... ...........PHONE................................................................................. :Z ,. <br /> PHONE <br /> r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms .... .. �• <br /> 2. New Building Details �• �: o <br /> New Building Type of Construction: No. Bedrooms ... Aw G <br /> Addition <br /> .......... .................................................... Septic Tank Size Gals. ...... Q < <br /> Sanitary ... Size .............. ft. x .............. ft. ......... <br /> Fillip /Gradin 4a. Absorption Field Site:g g Height............. Stories ...............Moving .......... Area Soil Type ................................... :N r i <br /> ......................................... <br /> Mobile Home Slope .......................................... �� 0 <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Well ...,,.,.., home,garage, motel, etc.) Dry Well p <br /> Subdivision ,,,,,,,,,, Seepage Trench .......... <br /> .................................................... <br /> Camping Unit .......... Privy p........ 91 . <br /> .................................................... Seepage Bed <br /> ————————————————————————— <br /> ----------------------------------- -------- i7N <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc.,should be sketched in Fig. A. Include road <br /> 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 'intersection. CLEARLY LABEL EXISTING <br /> N a <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. Uo <br /> ------------------------ ----------------- <br /> 5. Lot Size: Fig, A. 6. Location: \ 'Ij <br /> ................ ft. x .............. ft. . ............................... sq. ft. ............................................................................... <br /> V� o0 <br /> w <br /> . f7 s A d is�� op rt Z Z <br /> r <br /> f ! N <br /> A d no <br /> m mZ <br /> E <br /> a <br /> an 5. a -0 o ,. � yam <br /> 5@ o O n m <br /> in 3 <br /> � <br /> � � S <br /> n <br /> 0 <br /> Signature of Owner or Agent Date <br /> Remarks <br /> z � , x m <br /> .. ..`. ...... .........:........................................'................................................................................................ 0 <br /> ....................... Z..ru ck�J...i2?•er�f .................................................................................................. <br /> ma1r // ............................ <br /> ......... ............. . . . . <br /> N <br /> T <br /> Inspection Date 75 ....." <br /> m <br /> Zoni Administrator 8 88 8 fn <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 tie made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />