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l, 1 <br /> Burnett County Office of Zoning Administrator c - H z <br /> 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT - 3 <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as H -,• 1,3 <br /> tn <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use CD c <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3- a i N- <br /> 0 <br /> OWNER, (please print) CO TRACTOR or SURVEYO�ENT CD <br /> t/L/ y.•4// `�793 c s'? \ �.T <br /> ADDRESS ADDRESS m q <br /> L l,J/ 57?93 _ �' <br /> ADDRESS ADDRESS <br /> PHONE PHONE • l <br /> PLUMBER WELL DRILLER <br /> v <br /> ADDRESS ADDRESS m CI r <br /> o <br /> o' ,* <br /> PHONE PHONE Z H • <br /> o <br /> DESCRIPTION 4. Sanitary Facilities: . o o <br /> 1. Work: 2. New Building Details No. Bathrooms <br /> New Building Type of Construction: No. Bedrooms 0 <br /> Addition Septic Tank Size Gals. <br /> Sanitary Size ft. x ft. <br /> Filling Height Stories 4a. Absorption Field Site: <br /> Moving Area Soil Type o <br /> Grading Slope p <br /> Mobile Home 3. Use (describe exactly, 1 -family Perc. Rate h <br /> r <br /> Privy home,garage, motel,etc.) Dry Well :tS%. <br /> Well Seepage Trench ' <br /> Ni <br /> Subdivision Privy <br /> Seepage Bed <br /> rn <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road 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- a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING y• <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> o• <br /> 7 LA <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ft. x ft. — sq.ft. <br /> ae <br /> 9, 1 �' Cl <br /> Di c.n <br /> CD <br /> ;J <br /> I ayy <br /> q F yi) Q.I o <br /> co o <br /> u J P\) v <br /> �N o <br /> I i 1- <br /> t 0 <br /> Is <br /> T `k <br /> 1-- ... <br /> . <br /> _ !`It o <br /> Do <br /> a) <br /> CO <br /> ram, <br /> CD <br /> r-\ f\ S <br /> 1 c -UC coZ <br /> CD C a =, CD DC CD <br /> N6a7 M. 0. < - ' a <br /> D <br /> C11 < d 5' 0 -a <br /> aH;ro .< cc * m <br /> Z o o `D . f X) <br /> • C 3 <br /> 01 Eft CC <br /> -,7 ZY �ig <br /> ° 0 <br /> Signature of Owner or Agent Date ° — <br /> X 7) <br /> Remarks 11 m <br /> CD v <br /> CD <br /> Eft <br /> ..0 II <br /> a-n <br /> Inspection Date ,/- .,a►-�„,, m <br /> 1° 00000vNim <br /> rn <br /> Zoning Administrator et/ o0000off.4 <br /> IOTE: 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 /> lis application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> tg until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> 'ith 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 />