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Burne-ttQ&unty. Office of Zoning Administrator 3 CD 0 o <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 <br />shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use CCD m <br />Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. B <br />D/CK r... .� - <br />............................... <br />OWNER (please print) CONTRACTOR or SURVEYOR or AGENT a <br />'7. ...l T .M. a14k..40..k........... .................................................................................. <br />ADDRESS ADDRESS <br />L Loo /U To x% <br />n <br />ADDRESS ADDRESS <br />............................................... <br />PHON PHONE <br />. %/./U.��.f=./11 0/./....................... ......... � ` <br />.w�............................................ <br />PLUMBER WELL DRILLER �,Z <br />S//...%.. ....................................................................... <br />„..... _ > <br />ADDRESS ADDRESSCD <br />���5 o <br />o' <br />< <br />PHONE PHONE Z y r <br />DESCRIPTION 4. Sanitary Facilities: ° o ° <br />1. Work: �r 2. New Building Details No. Bathrooms o <br />New Building /t ... Type of Cons �.�t i No. Bedrooms 2.. ti <br />Addition /Xh:. Septic Tank Size Gals. <br />.. Z Op <br />Sanitary... Size ..�y.... ft. x ... �... ft. f�U�I�!/UG 7�fillK Q9�: w <br />Filling Height ............. Stors�...�......... 4a. Absorption Field Site: ; <br />Moving Soil Type ./!?.C� .................. h <br />.. <br />......... Area....,l.Q.516..................I... � R �IT o <br />Grading Slope.........t'.r�.0...�.I.............. o `` <br />Mobile Home .......... 3. Use (describe exactly, 1 - family Perc. Rate ........1Y.................... �3 `�- <br />Privy ......... home, gara e, motel, etc.)/ - Dry Well ry <br />Well.... 7�.F/J/�,L ...FYC)r� Seepage Trench <br />Subdivision Privy _ <br />............................................................. of 1k <br />Seepage Bed .......... <br />7'1 Cn <br />V ! <br />Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road pvA� W RI . � C : $ <br />setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter-dam <br />section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br />N <br />STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. C) p o <br />----------------------------------------------------- <br />5. Lot_Size: Fig. A. 6. Location: � nr C <br />...ZOn ,�J/ <br />ft. x . /00. ft. - ...P.Q�..... sq. ft................................................................................ V <br />m <br />a �^► :rte 0. <br />rt <br />0 <br />_ <br />:id s <br />:0 <br />CD <br />•� coljV\ <br />d <br />_ <br />ra <br />cn r� cn w' <br />CD c CO �. � 3 C co <br />m. Naas _,..;_� <br />d <br />o cn<C: - <br />O N N < C <br />Z o o. (D `C° <br />l).1 0 -� <br />P\CD <br />o 70 <br />.. <br />:.............................................................ay <br />C <br />Signature of Owner or Agent Date ` ' <br />�` X 70 <br />Remarks..!.tsl/...L............................................................................... Co ;U <br />-n m <br />.......................................... v <br />CD <br />oq <br />.............. <br />-....... <br />.................................. <br />% '..L..................................................................... Q <br />... .. <br />Inspection Date .............. ....mGO 0 0 0 o u, rmn <br />g� ................ <br />Zonin Administrator 0 0 0 0 0 f/) <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 />