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Burnett County Office of Zoning Administrator 00 ID --I 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3 D <br /> 0 <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 N\ <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin_ 3 a <br /> a <br /> yO <br /> .......J:...� :. ...w �.h. $. . .... . .... ...... _ f� <br /> OWNOhpleaga print) CONTRACTOR or SURVEYOR or AGENT a <br /> ..........((CP;)C� .1 <br /> . ................... ............................................................................................ <br /> ADDRESS ADDRESS <br /> a.M1........��'.L.....sf��...... <br /> ADDRESS ADDRESS G\ <br /> 35 /vs <br /> PHONE . - PHONE <br /> Jilit......................................... ...... ....... . . <br /> PLUMBER WELL DRILLER <br /> O <br /> ................................................................ .. 'D'D"RE,S".............................................................................. 0 0 9 <br /> ADDRESS ADDRESS m � <br /> o <br /> ........................................................................................... ............................................................................................ .�.' <br /> PHONE PHONE Z <br /> DESCRIPTION 4. Sanitary Facilities: U o 0 0 <br /> Ss v <br /> 1. Work: 2. New Building Details No. Bathrooms .....e z <br /> New Building No. Bedrooms <br /> g ...,✓, <br /> Addition ..........Type of Construction: <br /> Septic Tank Size Gals. .....CJ. w <br /> Sanitary .......... Size .............. ft. x .............. ft. ......... _ <br /> FillmgiGradmg .......... Height............. Stories ...l........... 4a. Absorption Field Site: <br /> Moving ....I..... AreaSoil Type .................................... C o <br /> ........................................... <br /> Mobile Home .......... Slope .......................................... <br /> O <br /> Privy .......... 3. Use (describe exactly, i -family Perc. Rate ................................... ... <br /> Well ...,,,,,,, home, garage, motel, etc.) Dry Well .......... IL <br /> Subdivision Seepage Trench .......... <br /> ....... e. .u.9t................. <br /> Camping Unit ........ SeePrivy """"" ' <br /> (31 <br /> .................................................... Seepage Bed 90 <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- t a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection_ CLEARLY LABEL FXISTING <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> ----------------------------- <br /> 5. Lot Size: y Fig. A. 6. Location: i <br /> ................ ft. x .............. ft. — ...... ,3G J sq. ft. .............. ........................................................... be. <br /> r o <br /> c' O 3 <br /> - � 3 <br /> tD <br /> Tb <br /> 's <br /> T <br /> X F. <br /> IL <br /> be w�v � �= m Z <br /> c m <br /> oN. � : rr <br /> Z o o' > x <br /> o n m 3 <br /> to <br /> !-fa o' <br /> Pit <br /> Sig ture of Owner or Agent to — <br /> X z <br /> T <br /> Remarks ......................................................................................................................................................................... rr� � <br /> : <br /> <» <br /> ........................................................................................................................................................................................ — . . . . <br /> ............................................................................................................... ............ ... .......................................... « <br /> Inspection Date ....................................... .. <br /> Zoning Administrator coo <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 51-11111 <br /> Inguntil a permit has been issued. A permit may be revoker) it 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 />