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Burnett f'iunty ~A_ _ Office of Zoning AominisVator iv -C o o ` <br />APPLICATION FOR SANITARY; LAND USE — BUILDING PERMIT <br />v o <br />TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < <br />shown`ii�&rein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use CD <br />Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. a Jv <br />`....... iF� i.E%7 c'n : L <br />:................... .......................................................................................... 0 <br />OWNER (please print) CONTRACTOR or SURVEYOR or AGENT co <br />.......... C ; <br />ADDRESS ADDRESS + ' <br />ADDRESS ADDRESS <br />............................................................................................................................................................ <br />............. ............. . <br />PHONE ' PHONE <br />PLUMBER WELL DRILLER i <br />..."'E'S".............................................................................. <br />ADDRESS ADDRESS....r C o <br />+ 0 <br />............ z N r <br />PHONE PHONE <br />DESCRIPTION 4. Sanitary Facilities: ° o ° <br />1. Work: 2. New Building Details No. Bathrooms <br />9y o <br />New Building No. Bedrooms .......... L <br />.......... Type of Construction: <br />C <br />Addition Septic Tank Size Gals. .......... <br />...............ti..... ..................... �+ <br />Sanitary .......... Size ........:..... ft. x .............. ft. .......... <br />Filling/Grading 4a. Absorption Field Site: 'v <br />.......... Height ............. Stories ...............i <br />Movie Area ............... O1 Type o <br />Mobile Home.......... Slope .......................................... i <br />PrivPerc. Rate ................................... i <br />Privy .......... 3. Use (describe exactly, 1 • family <br />Well .......... home, garage, motel, etc.) Dry Well .......... i <br />SubdivisionSeepage Trench .......... <br />.............................................................. <br />Camping Unit .......... Privy .......... (N <br />.................................................... <br />-------------------------------------------------- Seepage Bed------------ <br />C <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- I a I <br />section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING d <br />STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. H <br />o' <br />--------------------------------------------------------------------- <br />5. Lot Size: Fig. A. 6. Location: <br />................ ft. x .............. ft. — ............................... sq. ft................................................................................ t t <br />N p <br />O <br />p <br />7 <br />7 <br />CD <br />OZ ; X <br />Do <br />V' CD <br />(p r -0CD C CD <br />W <br />CD <br />F <br />a <br />Ln <br />�« U; ; - m <br />Z O o . y a <br />O M . : : : a� <br />ER - <br />OIM <br />IM <br />................................................................-y.......... r a <br />Signature of Owne or Agent Date <br />X 70 <br />emarks......................................................................................................................................................................... <br />-n m <br />CD <br />M <br />........�....... <br />`� �Q. N m <br />"tion Date ....................................... ?zf.......................f..... ............................... o: o cNn o c°n o cn <br />Zoning Admi istr�✓ 000000N <br />liminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br />,ction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br />be it will be issued. Do not purchase or install a septic tank, do any plumbing or start any build - <br />d: A permit may be revoked if misrepresentation of any of the information conveyed here- <br />in plans or specifications shall not be made without approval of the Zoning Administrator. <br />NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />s <br />