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F ^ R i(, <br /> Burnett County Office of Zoning Administrator c - o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT '� <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as H o <br /> 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 e c.r\ <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. a <br /> v <br /> OWNIplease print) CONTRACTOR or SUR YOR or AGENT aCD <br /> F2... t , <br /> ADDRESS ADDRESS CD <br /> ADDRESS ADDRESS . .— <br /> PHONE PHONE C� <br /> GJ <br /> PLUMBER WELL DRILLER <br /> 0 <br /> ADDRESS ADDRESS m G) f <br /> n o <br /> o ,- <br /> PHONE PHONE <br /> DESCRIPTION o ,- o <br /> 4. Sanitary Facilities: ° o e- <br /> 1. Work: 2. New Building Details No. Bathrooms -n <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 TypeIcT <br /> Grading Slope ° <br /> Mobile Home 3. Use (describe exactly, 1 -family Perc. Rate 5,) <br /> Privy home,garage,motel,etc.) <br /> Dry Well I <br /> Well Seepage Trench <br /> Subdivision Privy 1 <br /> Seepage Bed � cn Location of proposed structures and existing structures, well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road <br /> cs ON <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- I a • <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING r--. <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. - <br /> 0' <br /> 3 <br /> 5. Lot Size: Fig. A. 6. Location: <br /> -^T <br /> ft. x ft. — sq.ft. r <br /> 5tv aZ7-ekei-e-tia e5-//9 (---- (---' cn 44_ <br /> o <br /> o <br /> �af' / /70 -/72 chi o o <br /> _0 V <br /> N <br /> C—I <br /> G <br /> -. <br /> T <br /> m ,01 <br /> z <br /> 0 <br /> Da <br /> v <br /> c <br /> co <br /> m <br /> tai*- <br /> °1 <br /> � C r . c,ooc <br /> c m <br /> CD. N 0 Q .`L - .q.a � <br /> zffr oo' < � a' m <br /> o c _� <br /> •OMo <br /> Do <br /> 9- /-73 �� 0 <br /> Signature of Owner or Agent Date W° • C <br /> X D3 <br /> Remarks m m <br /> CDO <br /> �: u <br /> to <br /> �� • <br /> O • T <br /> Inspection Date >2 0 0 0 0 .cn m <br /> Zoning Administrator : AcD <br /> o 0 0 0 0 o ccn <br /> JOTE: 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 /> his application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> ng until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> vith 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 />