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Burnett County Office of Zoning Administrator 3 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ;;: �'; 3 O <br /> _ o <br /> TO TH€ ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as N <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a ;� <br /> p <br /> eli�e, �'��''� <br /> .................................... <br /> CDN...: ..................................�..�1. .nsc�`� <br /> OWNER (please printl_ CONTRACTOR or S RVEYOR or AGENT �.^ <br /> ................................. ........................... ........1.5�'�.O..Si:c.. n. . fr (� <br /> ADDRESS ADDRESS V <br /> 1 �1NK. K ....- '1.�-..�.c�. /............ ..... . . . ............... ......... (Lr..�JD.n.n�i.�)............. Q ` <br /> ADDRESS ADDRESS <br /> ...... .. ................................ <br /> ..... <br /> ........................... ................................................. <br /> PHO �. � PHONE <br /> ......................................... .................. ............. .... N <br /> PLUMBER t WELL DRILLER <br /> twvlq� '�. ........................... .............................. ..... .................................................... _. <br /> ADDRESS ADDRESS <br /> 0�, h o <br /> .....31.. ......4 .... ................................................ .......................................................................................... : O. rf :.• <br /> PHONE <br /> PHONE <br /> Z y <br /> r— <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> No. Bathrooms <br /> 1. Work: 2. New Building Details 0 : <br /> New Building No. Bedrooms ,3.... <br /> ......... Type of Construction: <br /> Addition .................................................... Septic Tank Size Gals. ��....... <br /> � rL <br /> Sanitary Size .............. ft. x .............. ft. <br /> Filling Height............. Stories ............... 4a. Absorption Field Site <br /> - <br /> Filling <br /> Moving .......... Area Soil Type ..............( - `D 0 <br /> Slope ..................... <br /> — <br /> Grading <br /> Mobile Home 3. Use (describe exactly, 1 -family Perc. Rate ................. ................. <br /> Privy home,garage,motel, etc.) Dry Well t" <br /> Well g g Seepage Trench .......... <br /> � .. ... <br /> Subdivision Privy t ... .,.... <br /> ....... ............................... <br /> Seepage Bed �$X 3 <br /> Cn <br /> ----------------------------------- <br /> --------------- -- .. .. <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road p, C7 <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- Q <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING41 <br /> ��—• <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: /� t /� �� Fig. A. i <br /> ...... ft. x ..130. ft. — .....!.........................QES sq.ft. <br /> i` <br /> CD <br /> N 3. <br /> o0 <br /> cn co <br /> d <br /> <. c <br /> k O N. <br /> Z O o `D < <br /> O _ <br /> O <br /> C <br /> .... .......... ... . ........7....� ........... ; o <br /> jSignat�u��reo�'f�Ovvner Agent Date T X n <br /> Remarks ............................................................................................................................................................................ <br /> CD <br /> C <br /> Ut <br /> ............................................................................................................................................. ............................................. M n <br /> Inspection Date ....................................... ."s`.. `` ` .................................... ` 666 ' o n <br /> Zoning Administrator O o o o co <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 plumhing 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 />