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Burnett County Office of Zoning Administrator iv o 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 y <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use c <br /> Ordinance, Sanitation Code,and with allother applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 cD <br /> . .. ..................1 .. ../................... ........................... . C/.1�..... ............................. <br /> y <br /> OWNER lease print) CONTRACTOR or SURVEYOR or AGENT a <br /> ... :.....� ................................................ ......................................................................................... <br /> ADDRE.S.S ADDRESS rt <br /> 1.d. .i. CD <br /> !u e., /........, ..4..�.,..... U ....... ......................................................................................... <br /> AD RESS ADDRESS <br /> ........................................................................................... <br /> PHONE � <br /> PHONE <br /> .......... <br /> PLUMBER WELL DRILLER <br /> 0....................................................... .......................................................................................ADDRESS AD..DRESS <br /> no <br /> PHONE................................................................................ ............ j <br /> PHONE z H � <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms r <br /> New Building ,.,,,,,,,, Type of Construction: No. Bedrooms .......... , <br /> Septic Tank Size Gals. .......... ; Z+Addition .......... .a m.`........................... p � v <br /> Sanitary .......... Size .... ft. x ...a?.d..... ft. .......... ? <br /> Filling Height.... .... Stories .../........... 4a. Absorption Field Site: <br /> Moving .......... Area ....aZ.U.U..J ...fTS Soil Type .................................................. <br /> p ..................Grading � � • <br /> Mobile Home 3. Use (describe exactly, 1 family Perc. Rate ................................... c <br /> Privy .......... home,garage, motel, etc.) Dry Well .......... <br /> Well .......... .......... Seepage Trench .......... <br /> .............. ; <br /> Subdivision Privy .......... i <br /> _�lYl� E_� I�$G --------------------------- Seepage Bed--- ......... �C <br /> N <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig. A. Include road n <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 ` < <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> ---------------------------------------------------------------------- <br /> t' p <br /> 5. Lot Size: 4M&C Fig. A. 6. Location: <br /> n <br /> .... ft. x ... ft. — ............................... sq. ft. ..............A4.04.P..Nd.............7:........ <br /> i.l. <br /> P <br /> -- :� Co <br /> n-e <br /> p <br /> a z <br /> Z o <br /> f0 <br /> on, <br /> ti Lo <br /> CD <br /> I� t k� - /[?flex -/� �' Cro 7 <br /> -_ z <br /> S �/ 0 U3 6 7 C . E <br /> m <br /> m <br /> z o o `D <br /> o �. <br /> L <br /> o � <br /> m <br /> p <br /> iignatur f Owner or Agent ate 1 0 C <br /> X 70 <br /> 3ema <br /> CD <br /> CD <br /> ....................................................................................................................................................................................... . . <br /> ...................................................................................................... <br /> ?O <br /> J.............. : ro: �» <br /> p G � / Q � � � o 3rQ 000 <br /> nsection Date ....................................... . ........ ....... .....:.......g................. ... . : o 0000 0 0 o m <br /> Zonin Administ ator o 0 0 o f/) <br /> OTE: 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 /> tis application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> rg 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 />