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Burnett—County— Office of Zoning Administrator W CD o 0 <br />APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT o <br />TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as N ' "J\ <br />shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use CCD <br />I CD <br />Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a ;� <br />D/ew /4F ........ <br />.................................... ...................................r..................................................... <br />OWNER (please print) CONTRACTOR or SURVEYOR or AGENT (D <br />$"....(7.0....c...R.............. Q <br />ADDRESS ADDRESS <br />ADDRESS ADDRESS � .\ <br />............................................... .................................. <br />PHONE_PHONE \ <br />ry�s1�............................................. <br />PLUMBER WELL DRILLER \ :� <br />g9.3............................................................................................ o <br />ADDRESS ADDRESS 0 <br />< <br />... '7�-................................................................... 0 r. <br />...................................... ...................... <br />PHONE PHONE Z ti r <br />DESCRIPTION 4. Sanitary Facilities: ° o ° <br />1. Work: No. Bathrooms ... �... <br />2. New Building Details 2 i� o <br />New Building /.:r... Type of Cons ��{{�;tiI No. Bedrooms N <br />Addition %WOO�t„ /'/�}.!'!'�, Septic Tank Size Gals. .......... <br />..... <br />Sanitary vv ,,}} /-/0/,,0/ 6 _MkI ZOAOGIt. <br />11.... Size ..y.... ft. x ...7.... ft. <br />Filling ....•..... Height ............. Sttories/....I...... ... 4a. Absorption Field Site: : <br />g ....1..Q5,f� ...................... Soil Type ./?. ................ <br />Moving Area ��.. <br />Grading Slope ......... ...p ........................ u r <br />Mobile Home .......... 3. Use (describe exactly, 1 - family Perc. Rate ........ ................ <br />Privy Dry Well F <br />„•• „•,, home, gara e, motel, etc.) """"" <br />Well ...... F/%f/� (.1�%'%� Seepage Trench Mcg <br />... <br />Privy ; <br />— Subdivision """"" <br />Seepage Bed .......... v ? 1 i� <br />_____________________________________________________ �, V! <br />Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road 0 S <br />setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter -P `^r (� 0 - <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. C) O �;O 0 <br />— — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — <br />5. Lot_Size: Fig. A. 6. Location: V, V, <br />Q� ft. x .7..Q.. ft. — ..�.P...... sq. ft. Cn <br />lJ i\ <br />CD <br />ic­ <br />0 <br />_ <br />�'► :cin �. <br />z <br />0 <br />CD <br />� NQQ< <br />d <br />6 Vl < <br />C: <br />0 L'. N <br />Z O oID fD <br />� 5 _ <br />l�) 0 —i <br />�0 <br />...CD <br />....................................y. <br />Signature of Owner or Agent Date <br />X. <br />� ............... CD m <br />Remarks .. <br />CD <br />V M <br />to <br />.......................................................................................................... <br />..........%Gf.... ........................................................................................................ <br />Tt <br />Inspection Date ...: ".�G....r.�f 7........... 4 �m .. t..�y.L �................ o o b ' b b m <br />Zoning Administrator . . 0 0 0 o o c/) <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 not 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 />with 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 />