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Burnett County Office of Zoning Administrator o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. \ <br /> TO THE 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 CCD c <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 CL N <br /> a <br /> N <br /> .. p ..t. .. ..V...S.. o <br /> OWNER ( leas rint) CONTRACTOR or SURVEYOR or AGENT a <br /> t 3 3 c� ....C--.er # . ..�`.r.......... <br /> ...... . ................ .... .................... ............................................................................................ . . <br /> ADDRESS ADDRESS <br /> D <br /> ..ri.�f........ .. rt.�.. .......k�.t. .............................. ............................................................................................ <br /> ADDRESS ADDRESS <br /> ........................................................................................... ............................................................................................ mph <br /> PH04 PHONE <br /> PLUMBER WELL DRILLER ?fir <br /> AD......D.....RES................................................................................ :� h <br /> ADDRESS S <br /> ............. o <br /> PHONE PHONE Z N <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° :A. <br /> 1. Work: No. Bathrooms T <br /> 2. New Building Details :'�• o ; <br /> New Building .......... Type of Constrtictign: No. Bedrooms .......... <br /> Addition ,,, ,�{�S,•%/�.t ,,,••„••,• Septic Tank Size Gals. .......... <br /> v <br /> :`tz <br /> Sanitary ......•••• � <br /> Y Size .............. ft. x .............. ft. <br /> Filling Height............. Stories ............... 4a. Absorption Field Sit ; <br /> Soil Type ............... ..0.. .Q. <br /> Moving .......... Area ......................................... o <br /> Grading Slope ............. . !i <br /> Mobile Home 3. Use (describe exactly, 1 -family Perc. Rate ... �.......:.�.``.. <br /> motel etc.) <br /> Privy .......... home,garage, , Dry Well .... �j <br /> Well „••,,,•• Seepage Trench .......... <br /> ...................................................Subdivision Privy ...0..•••• 4 <br /> .................................................... <br /> Seepage Bed .......... oe ; <br /> ---------------------------------------------------------------------- ;�. 'cf) :, <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road `C s <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 i <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. C, ; o•_ <br /> ---------------------------------------------------------------------- W Z) <br /> 5. Lot Size: . <br /> Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... <br /> ' c <br /> N • o� <br /> o <br /> N :S <br /> rF C <br /> O <br /> 3 <br /> L: : T <br /> CD <br /> Z <br /> 3 <br /> CD <br /> �o Cn r Ca Z <br /> cn = m �. CDm c co <br /> �'a � <br /> cn < C . <br /> 'G fC g m <br /> Z O OCD <br /> O �= 3 <br /> m <br /> ��—�7 3 A <br /> ................... o C <br /> Signature of Ow r or Agent Date �* <br /> QQ' o <br /> Remarks ..✓... r.��' arc ���,2 3 T <br /> CD <br /> CD <br /> .......................................................................................................... Q <br /> Inspection Date!? 1......... ...... <br /> T <br /> 00000cNnm <br /> JCS............ 000000m <br /> Zonin Administrator 0 0000 0 (n <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 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 />