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Burnett County Office of Zoning Administrator v -0 --1o Jf <br />APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br />TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as H o <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 />Ordinanc ,- Sanitation Code, and <br />withAl other applicable County Ordinances and the laws and regulations of the State of Wisconsin. a - J : U•� <br />....... --e: C.r.�! v........... l... l f�-�J t! <br />�(.....:............ <br />OW (please print) NTRACTOR or SURVEYOR or AGENT a CD <br />` ^ <br />...fry. G�....�!�U...... ............................................................................................. <br />A Qn t�5S ADDRESS o <br />........... <br />ADD ESS ADDRESS :• <br />PHONE PHONE <br />........................................................................................................................................................... <br />PLUMBER WELL DRILLER <br />O <br />ADDRESS ADDRESS c� L) <br />h o <br />........................................... <br />.................................................................................................................... O <br />...... .. ......... <br />PHONE PHONE... z H <br />DESCRIPTION 4. Sanitary Facilities: ° o ° <br />1. Work: No. Bathrooms 0 <br />2. New Building Details o <br />New Building ✓ Type,0 Construction: No. Bedrooms ....... CD <br />z <br />9 Septic Tank Size Gals. ' <br />Addition ....... .�C.r.. p <br />Sanitary ...... Size ....% x <br />�a...... ft. <br />Filling/Grading Height Stories 4a. Absorption Field Site: i <br />........ <br />Moving.......... Area Soil Type.................................... r <br />SlopO <br />Slope Mobile Home .......................................... o ; <br />.......... <br />Privy .......... 3. Use (describe exactly, 1 - family Perc. Rate.................................. <br />Well .......... home, gar ge, motel, etc.) Dry Well .......... <br />Subdivision�q:,.� Seepage Trench I; <br />Camping Unit <br />Privy <br />Seepage Bed .......... -� <br />----------------------------------- ----------------------------------- v <br />M <br />Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road VI c <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 />N <br />STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br />------------------------- D <br />5. Lot Size: Fig. A. 6. Location: <br />ft. x .............. ft. — ............................... sq. ft. <br />N <br />0 <br />N O <br />O <br />0 <br />� 7 <br />:t <br />Z <br />Q o <br />CD <br />ro <br />w <br />:LK <br />M c r-o� ID m W <br />C Q n m n F <br />N -. C � <br />Z Oo D a <br />O _ O aro <br />(AA U7 o <br />(-A Ln <br />. . . . . <br />�...:...................�.../.. o <br />Signature of Owner or Agent Date '`� rt C <br />X 70 <br />Remarks......................................................................................................................................................................... -p <br />CD . <br />.......................................................................................................P ..................... . . . . . . <br />............................. T <br />to T1 <br />Inspection Date....................................... 0/ 7� '0 N CO N m <br />.................................. I............... o cn o cn o yr <rT1 <br />Zoning 000000 0 0 0 0 0 N <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 riot 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 />rvith is found to exist. Changes in plans or specifications shall not be made without approval of the Zoning Administrator. <br />1 SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />