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Burnett County `��—�a Office of Zoning Administrator ,�', o z <br /> 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT h 3 <br /> -,r m r+'TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as o 0 ?® <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use <br /> CD C <br /> Ordinance, anitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 Q C>f <br /> _' a `�,/� <br /> O <br /> .....:�... -r.r,&-s........da��.y................................. .Ge.►.�t IJ...... . . . !-�.ex-................................... y � � <br /> OWNER (please print) CONTRACTOR or SURVEY or AGENT a <br /> ..................................... AVS.1.ES .✓..C°.�/.(:n.......................... <br /> ADDRESS <br /> CD <br /> ADDRESS ADDRESS <br /> .......... <br /> PHONE PHONE ?- <br /> N1 <br /> .......... �p <br /> PLUMBER WELL DRILLER Jai <br /> .......... ! <br /> ADDRESS ADDRESS O <br /> n o <br /> PHONE ............ o <br /> PHONE <br /> DESCRIPTION z N r <br /> 4. Sanitary Facilities: ° 0 ° <br /> T <br /> 1. Work: 2. New Building Details No. Bathrooms o <br /> New Building .......... Type of Construction: No. Bedrooms <br /> Addition .................................................... Septic Tank Size Gals. .......... i h <br /> Sanitary .......... Size <br /> Filling .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> MovingSoil Type .................................... <br /> .......... Area ........................................... yp r <br /> GradingSlope .......................................... <br /> O <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 „✓ Privy .......... : <br /> ................................................... Seepage Bed <br /> ------------------------------------------------------------------- <br /> Location of proposed structures and existing structures,well,sewage systems,roads,etc.,should be sketched in Fig. A. Include road 6 <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 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> o' <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... <br /> 1 N <br /> O j <br /> C <br /> CD <br /> Z <br /> CD <br /> :X <br /> Al <br /> fD. Naa < + a <br /> OHH � tG $ rn <br /> Z C)F) : m <br /> —:3 3' <br /> La <br /> �Q o <br /> ID <br /> m <br /> ........ ... c <br /> Signature of Owner or Agent Date W X <br /> Remarks s -n vm <br /> ........................................................................................................................................................................................ <br /> jug, ' <br /> ............................................................................................................... ...... ........................................ .�I <br /> Inspection Date ....................................... . . <br /> ...... <br /> O Ppp i-� m <br /> Zoning Admi trator : �: c o 0 0 0 0 o U) <br /> DOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> lefore 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 /> ✓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 />