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Burnett County - Office of Zoning Administratord 0 0 <br />APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT <br />TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < H 0. <br />shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use c V <br />Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a ' <br />�� q ........Ja a a...F...................... ........or.................................................................... y <br />OWNER (please prin CONTRACTOR SURVEYOR or AGENT CCD <br />CL <br />CLoX....6................................................................................................................................................... <br />ADDRESS ADDRESS <br />u.s...:.......5yg:....Q............................................................................................. <br />ADDRESS ADDRESS <br />l.�G...... 7 .05 ............................................... <br />PHONE PHONE <br />........... <br />PLUMBER WELL DRILLER :r <br />................. <br />................................................................. D <br />ADDRESS ADDRESS <br />CD G7 <br />h o <br />< <br />............................................................................................................................................................. O <br />PHONE PHONE 0 <br />Z H r <br />DESCRIPTION 4. Sanitary Facilities: ° o ° <br />1. Work: No. Bathrooms 0 <br />2. New Building Details o <br />New Building .......... Type of Construction: No. Bedrooms <br />Addition ✓ .,,,...... '�„ .��.. Septic Tank Size Gals. .......... <br />..... <br />SanitarySize ...... .... ft. ......•••• <br />1... ft. x .... �.�P <br />Filling/Grading .•.......• Height ....s ..... Stories ....0/)( 4a. Absorption Field Site: <br />Moving .......... Area ....s SSP Soil Type .................................... o <br />,... <br />MobileHome Slope .......................................... )... , <br />.......... <br />Privy 3. Use (describe exactly, 1 - family Perc. Rate ................................... <br />Well ...I..••.. home, garage, motel, etc.) Dry Well .......... <br />SubdivisionSeepage Trench .......... <br />.......... ..........1��?. f Gf.................... <br />Camping Unit Privy .......... <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 M <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. 0 <br />-------------------------- ----------------------------- D <br />5. Lot Size: Fig. A. 6. Location: <br />................ ft. x ft. — ... sq. ft. <br />m <br />ems' N O • <br />O 7 <br />7 <br />0 :�j <br />N <br />V � 7 <br />N <br />. 1 3 <br />-n <br />CD <br />Z <br />0 <br />O <br />m <br />:G <br />�7 cn r v w W Z <br />CD o < c' F <br />CD CL <br />y•C, . - m <br />Z OO �a 3 <br />o a <br />0 <br />-Q— <br />..................................�-..�.-.G. :::::: m <br />0 ::::::p <br />Signature of Owner or Agent Date ° C <br />X <br />-n m <br />Remarks......................................................................................................................................................................... CD C <br />CD <br />En <br />........................................................................................................ ..................... .......... <br />S <br />Inspection Date ....................................... �r7??,G✓. ..yl ..... ?................... l o L" o 0 o Pm <br />Zoning Admini rator tc ✓ 0 0 0 0 0 0 N <br />gOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br />)efore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br />his application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build - <br />ng until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br />vith 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 />