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Com" <br />Burnett County Office of Zoning Administrator Cn _V y� z <br />0) <br />CD 0 0 <br />APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <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 c <br />Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. <br />�� _ 0 <br />.................................................... .IEO� <br />................................................................................. C fD <br />a � <br />i <br />OWNER/(please print) RACTOR o URVEY0R or AGENT a M <br />a <br />ADDRESS ADDRESS � <br />...........l........... .:..9.. ........................... <br />ADDRESS AD.D..RES.....S.. ........ <br />............ <br />PHONE PHONE <br />.......... <br />......................................................................................LL... <br />..D..RI........LLER .............................................................Y 1 <br />PLUMBER WE <br />.......... <br />ADDRESS ADDRESS <br />PHONE PHONE <br />:Z o r <br />DESCRIPTION 4. Sanitary Facilities: ° 0 ° <br />1. Work:No. Bathrooms T <br />2. New Building Details ......•••• o <br />New BuildingType of Construction: No. Bedrooms L <br />p <br />Addition <br />Septic Tank Size Gals. <br />••.••..•.. <br />Sanitary .......... Size .............. ft. x .............. ft. .......... <br />Filling/Grading Height Stories 4a. Absorption Field Site: <br />............. ............... <br />Moving Soil Type.................................... r- <br />.......... Area........................................... <br />Mobile Home Slope.......................................... o 0 <br />Privy.......... 3. Use (describe exactly, 1 -family Perc. Rate................................... <br />Well .....•.... home, garage, motel, etc.) Dry Well .......... <br />Subdivision ✓ Seepage Trench ......... <br />Camping Unit. <br />.................................................... Privy <br />.................................................... <br />Seepage Bed .......... K4 <br />-------------------------------------------------r---------- Cn <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- fl <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. <br />r <br />5. Lot Size: Fig. A. 6. Location: <br />ft. x .............. ft. — ............................... sq. ft................................................................................ <br />CD <br />gee <br />I <br />N 0� <br />o <br />to <br />V 1 �J 0 <br />� I � <br />3 <br />70 <br />_n o <br />d <br />Co <br />t7-: <br />- w W Z <br />2. c mm a fm yam <br />o x970 <br />�0 <br />i--•�. �!� :::::: <br />................................ o <br />Signature of Owner or Agent Date - . <br />X M <br />Remarks _n k4j m <br />CD <br />CD <br />........................................................................................................................................................................................ <br />............................................................................................................................................................................ : \ <br />Inspection Date....................................... �11T1/�1.1........... � � ........................ 1° o o c, C, N <br />e <br />Zo ing Administrator `�� ° 0 0 0 0 0 0 <br />DOTE: 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 />