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Burnett County Office of Zoning Administrator 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. _ o <br /> 0 <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes appG,caticn 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 m iG <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. <br /> il..4... ..�1.......... ..�o . .N......................................... <br /> OWNE (please print CONTRACTOR or SURVFYOR or AGENT a '� <br /> J <br /> 5.../4.!`....... . .. ` ........................................................ ............................................................................................ <br /> ADDRESS ADDRESS <br /> Till <br /> ADDfl ESS ADDRESS i <br /> P..F.i......N............. .. ........... . . . .... . .. . P.HONE....... ..... . .................... ......... ............ ................................................................... <br /> .Q..E ........ . . ..... ..... . ..... ......... . ........ .... .. ....... .. .. . . . ................................................................................ <br /> PLUMBER <br /> CS <br /> WELL DRILLER6\ ;nrr <br /> ADDRESS ADDRESS m 0 <br /> �\ n O <br /> ........................................................................................... ............................................................................................ o M <br /> PHONE PHONE Z y <br /> r <br /> DESCRIPTION 4. Sanitary Facilities: �a o ° <br /> 1. Work: No. Bathrooms '�1 <br /> 2. New Building Details ""' o <br /> New Building No. Bedrooms <br /> .......... Type of Conffroo4 is3...... z <br /> °�C m <br /> Addition .. .....� .' <.S-,/.!r.. - ,,.... Septic Tank Size Gals. g w <br /> ........../ V E <br /> Sanitary C/ Size ft. x v ft. �t$ <br /> Filling .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving ....I..... Area ........................... ............. <br /> Soil Type ..................................... <br /> a <br /> Grading Slope ................................. ........ <br /> ¢ .. <br /> Pero. Rate ................................... <br /> Mobile Home 3. Use (describe exactly -family a <br /> Privy .......... home,garage, motel, etc.) Dry Well .......... � <br /> WellSeepage Trench .......... <br /> ............................... .................... <br /> Subdivision ,,,,,,.,,, Privy .,.0 ayii. . 'k} <br /> .................................................... Seepage Bed �.H.!`..� 0 1 <br /> Location of proposed structures and existing structures,well, sewage systems, roads, etc.,should be sketched in Fig. A. Include road .0 o <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. <br /> 0 <br /> r J � <br /> 5. Lot Size: Fig. A. 0 /� <br /> ................ ft. x .............. ft. . ............................... sq. ft. <br /> 4 N <br /> N O <br /> O J <br /> 3 <br /> O <br /> /c� <br /> 21 <br /> 1N :r <br /> Z <br /> O <br /> is <br /> n i <br /> CT D < <br /> Naa Jnr J'c <br /> NaM. <br /> _. <br /> Ej <br /> Z 00 ° 3 <br /> O _ J <br /> xg <br /> N <br /> :i�; 0 <br /> C <br /> .......... . .................................................. ...... ............................ <br /> Signa 're of ner or Agent Date 70 <br /> m x m <br /> Remarks ............................................................................................................................................................................ <br /> ........................................................................................................................................................................................... <br /> O <br /> .......................................................................................................�./...�...-.......................,..../....,.�..-........................................... : ' <br /> Inspection Date GV 1 ca m <br /> ....................................... .....:r�...................... ................................................ <br /> Zonin.9Administrator 00010C0 <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 it misiepresentd Lon of any of the Informdtion conveyed here- <br /> with is found to exist. Changes in plans or specifications shall not he made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />