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Burnett County Office of Zoning Administrator � - o <br /> APPLICATION FOR SANi'FARY,.— LAND USE — BUILDING PERMIT ] <br /> O O <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as H U <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m c <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 n. <br /> .+ °- O <br /> LU.THB1t..POIN.T..YI)1LE..CAMZ N <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT m m <br /> GRANTSBURG,..WI UM .54840 Q �v <br /> ADDRESS ADDRESS ,°++co <br /> ADDRESS ADDRESS <br /> 669-2347 <br /> PHONED�nall Daniels PHONE <br /> PLumiiren, WI 54872 -6.-( <br /> WELL DRILLER Q ; <br /> 11 NADDRESS ADDRESS O <br /> b3-2333 'N� a o <br /> PHONE PHONE Z ? , <br /> DESCRIPTION 4. Sanitary Facilities: o o o c' <br /> 1. Work: 2. New Building Details No. Bathrooms 2 <br /> New Building Type of Construction: No. Bedrooms 4 <br /> Addition Septic Tank Size Gals. 1200 Q <br /> Sanitary 8 Size ft. x ft. existing <br /> Filling Height Stories 4a. Absorption Field Site: <br /> Moving Area Soil Type <br /> Grading Slope ° <br /> Mobile Home 3. Use (describe exactly, 1 -family Perc. Rate <br /> Privy home,garage, motel, etc.) Dry Well <br /> Well Seepage Trench (1 <br /> MaAaSex..�..s ina.l.e...f a�i ly <br /> Subdivision Privy 0 <br /> him* X <br /> Seepage Bed <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc., should be sketched in Fig. A. Include road <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- O- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING 0 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. --C. o' <br /> O <br /> 5. Lot Size: Fig. A. 6. Location: ' <br /> ft. x ft. — sq.ft. <br /> V) <br /> n <br /> N O O• <br /> O O <br /> --1 <br /> O <br /> C <br /> S <br /> -. <br /> L. <br /> T <br /> MI <br /> CU <br /> 7 <br /> CO <br /> m <br /> fi <br /> D CO v 7 CO Z <br /> m c m <br /> co. Naa< — ,- a � <br /> o �• H � co 2 m <br /> Z O O CD <br /> O O <br /> • ft 7 g <br /> 01aa <br /> N O 33 <br /> . ,i9ewieddhe. f i/ 'JO -.F4 , CD <br /> Signature of Owner or Agent Date ° — <br /> Remarks -n x m <br /> co ca <br /> v <br /> ii <br /> ci' <br /> W ° -� � o m <br /> Inspection Date Y ° O O o 0 0 cNi, m <br /> Zoning Administrator 00000oN <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 /> ig until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> iith 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 />