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Burnett County Office of Zoning Administrator 3 - -- 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 Z, o <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use _ m <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> r+ a <br /> m � <br /> e e.rw ra .4� ............................. y <br /> .!- ......... .r .... .................................. <br /> OWNER (please print) CONTRACTOR or SURVEY r AGENT CD _. CD <br /> ADDRESS ADDRESS / <br /> . �t .r. W.,� ....... g... V <br /> ADDRESS ADDRESS <br /> ........... <br /> PHONE PHONE <br /> NO <br /> .......... U <br /> PLUMBER WELL DRILLER <br /> p :^ <br /> ADDRESS ADDRESS (D <br /> 0 < <br /> 0 o <br /> PHONE................................................................................ ............ o <br /> PHONE <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> 1. Work: 2. New Building Details No. Bathrooms .......... o <br /> New Building .......... Type of Construction: No. Bedrooms c......... <br /> Addition .......... .................................................... Septic Tank Size Gals. <br /> Sanitary .......... Size ft. x ft. ......•••• <br /> .............. .............. . . . . <br /> Filling .......... Height............. Stories ............... 4a. Absorption Field Site: i <br /> Moving Type Soil T e .................................... <br /> .......... Area ........................................... r- <br /> o <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 .......... <br /> ......... .................................................... . . . <br /> Subdivision <br /> .......... Privy.................................................... <br /> Seepage Bed .......... <br /> ---------------------------------------------------------------------- cn,-' ` <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road 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 5.-� <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o✓ <br /> 0 <br /> 5. Lot Size: Fig. A. 6. Location: a <br /> ................ ft. x .............. ft. - ............................... sq.ft. ............................................................................... <br /> - i <br /> C� 73 <br /> z <br /> r� <br /> 0 <br /> CD <br /> y c� C� €6 <br /> q cn r- cn ca z <br /> CD C . ECD <br /> Q N N •< (fl m <br /> QZ 00' fD <br /> • •• 'O <br /> o <br /> N W OQ ti^ M <br /> �'- .`.................... <br /> Signature of Owner or Agent o c <br /> Date- <br /> X 70 <br /> Remarks CD v <br /> ....................................................................................................................................................................................... <br /> ....................................................................................................................................... ................................... <br /> nspection Date ....................................... "... ...... . . .. .. o 0 0 0 o cn m <br /> Zoning Admini ator :1�": ° o 0 0 0 0 o Cn <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 /> its 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 /> 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 />