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Burnett County Office of Zoning Administratoro 0 <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 <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. 3 Q v <br />a . <br />%.....................................................1-60�u.......:.... a............................... <br />0 <br />OWNEWIplease print) RACTOR o CURVEYOR or AGENTCL <br />.........................A,DDRESS ....................................................... <br />ADDRESS � • <br />-(��r�-�,... f-vl.....�9...3........................... v <br />ADDRESS ADDRESS o <br />............................................................................................................................................ Q <br />PHONE PHONE <br />WELL DRI <br />.....LLER ....................................................................... <br />PLUMBER <br />ADDRESS ADRCD <br />DESS ....... <br />o <br />.............................................. o' <br />PHONE PHONE <br />Z N r <br />DESCRIPTION 4. Sanitary Facilities: ° g 0 <br />1. Work: 2. New Building Details No. Bathrooms ; o <br />New Building Type of Construction: No. Bedrooms .......... i L <br />CD ; <br />Addition <br />Septic Tank Size Gals. <br />Sanitary ......•... Size ft, x ft. ••.••.•••. <br />Filling/Grading ...•...... Height Stories 4a. Absorption Field Site: <br />Moving Soil Type.................................... : i <br />.......... Area........................................... o <br />Mobile Home Slope.......................................... <br />Privy3. Use (describe exactly, 1 family <br />Perc. Rate................................... <br />.......... <br />Well .......... home, garage, motel, etc.) Dry Well <br />Subdivision ✓ Seepage Trench .......... <br />.......................................... <br />Camping Unit Privy .......... : <br />.................................................... <br />Seepage Bed .......... <br />----------------------------------------------------------- ---------- 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- <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. N /\/-- <br />D v, <br />5. Lot Size: Fig. A. 6. Location: <br />................ ft. x .............. ft. — ............................... sq. ft................................................................................ <br />6 eel �2 172 Z10 <br />i7C <br />N j <br />v <br />� I I <br />r-+ o <br />CD <br />v <br />N r v m W Z <br />CD <br />CD <br />Q <m E. £ <br />.. y„.co-m <br />Z O p D a <br />O a <br />................................ o c <br />Signature of Owner or Agent Date 70 <br />X ....:. <br />Remarks m kV : : : : m <br />CD........................................................................................................................................................................................ <br />................................................................................................................................................................................... <br />Inspection Date....................................... A�Cl'4Q....e2r�Gi�..... ......... ........ 10 0 o °� o <br />T <br />m <br />m <br />Zoning Administrator $ $ $ $ $ $ N <br />NOTE: 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 />this 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 />