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S_ _ <br /> Burnett County Office of Zoning Administrator v � o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as '< N -h <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use � <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. o <br /> a <br /> n h/ r //�///� I�4. .E!. .�?��........................... <br /> .Mr`I..iI.G.Se'�. ........F�-1 �.�I.4.r. ..(...1.l.O.Y Fc4-4e��......� � O <br /> OWN R (please print)/ s CO TRACTOR or SURVEYOR or AGENT a <br /> n.b."r .....I�SJ. .................................. S/V.i°► �S a.Y1...-..... !.. ]Q. ............................. <br /> ADDRESS ADDRESS 1 C <br /> � ................................................ <br /> ADDRESS AW DDRESS. N <br /> ............ �► <br /> PHONE PHONE <br /> ........................................................................................... ............................................................................................ <br /> PLUMBER WELL DRILLER <br /> ADDRESS ADDRESS o <br /> ............................................................... P..H..ONE.........................................:.... ............... ....................... o <br /> PHONE z N <br /> DESCRIPTION 4. Sanitary <br /> Facilities: ° o ° J <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details o <br /> New Building .......... Type of Construction: No. Bedrooms .......... ti <br /> Addition .................................................... Septic Tank Size Gals. <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... <br /> Filling Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Soil Type .................................... r <br /> .......... Area ........................................... o <br /> Grading Slope .......................................... U) <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Privy home,garage,motel,etc.) Dry Well .......... I <br /> Well Seepage Trench <br /> Subdivision Privy .......... <br /> .......... .................................................... <br /> �J <br /> Seepage Bed .......... U0 <br /> ------------------- . <br /> --------------------------------------------------- I to <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road r_ <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- 1 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. N <br /> I o� <br /> ---------------------------------------------------------------------- �\ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... <br /> I. <br /> Cn <br /> co <br /> N o <br /> O �//;� <br /> :W <br /> O <br /> z <br /> 0 <br /> C <br /> v <br /> CD <br /> rnr7 <nmz <br /> co c c: �. d c m <br /> m z' — h'Q � <br /> a cn < C : <br /> o� H m <br /> 0 o? m <br /> cn `� -•I <br /> SO•o m <br /> CAI fJ <br /> Signature of Owner or Agent Date ° C <br /> x 70 <br /> Remarks mCD <br /> 0 <br /> {n <br /> ............................................................................................................ ............. ... ...... .I............................. N <br /> Ln <br /> Inspection Date ....................................... d'..'........... . o 0 0 0 o cn Im <br /> 0 00 0 0 0 <br /> Zoning Admini rator :•d: 0 0 0 0 0 0 cn <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 />