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--f- t _ h.Lr1 <br /> BurnettCovnty: Office of Zoning Administrator c o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 7 3 = :\ <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> ...V... ..Iy:.:U..... ..9..i:.. .(...'.'! .................................... ...............................................................I............................ O <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT <br /> aST.9.k.... ....:E�..°.�...3%l.s.............. ............................................................................... �) <br /> ADDRESS ADDRESS <br /> ADDRESS ADDRESS <br /> ........................................................................................... ............................................................................................ :`0 <br /> PHONE PHONE <br /> PLUMBER... ...... WELL DRILLE..R......... <br /> ........ <br /> ............................ <br /> ..... <br /> ....... <br /> .......... 4 <br /> ............................................... ...................................... ............................................................................................ O <br /> ADDRESS ADDRESS m L7 <br /> n O <br /> ........................................................................................... ............................................................................................ o .: <br /> PHONE PHONE Z H <br /> r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms o <br /> ....1... <br /> ✓ No. Bedrooms <br /> New Building ........ Type of Construction: - 3"' i m <br /> Addition .................................................... Septic Tank Size Gals. .......... < <br /> Sanitary .......... Size ..,la...... ft. x ........ ft. .......... <br /> Filling .......... Height Stories ....I........ 4a. Absorption Field Site: <br /> Moving .......... Area .............. o U..... .......... Soil Type .................................... ' o <br /> /....�... <br /> Grading .......... Slope .......................................... <br /> Mobile Home .......... 3. Use (describe exactly, I -family Rare. Rate ................................... i ' <br /> y <br /> Privy home,garage, motel, etc.) Dry Well .......... <br /> Well ✓ .............C''A�. ../N.................. Seepage Trench .......... i <br /> .......... <br /> SubdivisionPrivy .......... I <br /> .......... .................................................... <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 � 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- o- <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: �1 Fig. A. 6. Location: <br /> .1..4.o....... ft. x .............. ft. — ...Cr..L<. Sq�/sq.ft. ................... <br /> 0 3 <br /> tJ. <br /> n <br /> RKY SHcR t= �j p '� <br /> ;^C <br /> .yy Lc <br /> Rrr �_ d :o 0 <br /> 9 b <br /> G T Q <br /> 0D r I <br /> Z <br /> 0 <br /> Iy <br /> J ti <br /> � c d <br /> Z Go'm m <br /> O 3 <br /> M <br /> n C { o <br /> :`C 0 m <br /> Signature of Owner or Agent Date <br /> Remarks ....P..Q.rmi.tted..sani.tary...sXstem to be installed before occupancy. x v <br /> ................................................................................. <br /> » ' <br /> ' ' :—or m <br /> ........................................................................................................................................................................................ [ [ <br /> Inspection Date .....•................ 8800 <br /> 6 0 0 0 o m <br /> ...................................... ��1 °..•S'...........9.. ............. <br /> Zonin 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 />