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Burnett County Office of Zoning Administrator v CD o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT . <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as <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 <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 o_ <br /> d..................... 4f1............................ D. � . . . <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT a <br /> d.. ' . ......�5'T; T,� ............. ....... AS ............................................................ - <br /> ADDRESS ADDRESSCD <br /> ADDRESS _ ADDRESS S <br /> A .9.. .......6..., . . ............................................. ............................................................................................ <br /> PHONE PHONE <br /> ............................................................................ ............................................................................................ <br /> PLUMBER WELL DRILLER <br /> ........................................................................................... ............................................................................................ <br /> ADDRESS ADDRESS m 0 <br /> h o <br /> _. < <br /> . ................................................................................... ............................................................................................ .� N <br /> PHONE PHONE rf <br /> r <br /> DESCRIPTION 4. Sanitary Facilities: ° 0 ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details •• o <br /> New Building Type of Construction: No. Bedrooms ... ..... <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 ........................................... <br /> Slope <br /> Grading �« <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Privy .......... home,garage, motel, etc.) Dry Well .......... ` <br /> Well , '/�G•E/(1 N...... Seepage Trench .......... <br /> Subdivision .......... �70 C 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 c <br /> 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- _e <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 /> 0 <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location— <br /> ft. x .............. ft. — ............................... sq.ft. ��7.... ..lJ.........�-'l.l�/liJ jJA; :f <br /> r+ <br /> N — O <br /> O � <br /> 7 <br /> 0 <br /> 0 <br /> o <br /> �8 3 � a <br /> CD <br /> co <br /> CD C � �� � <br /> n� <br /> '� O w H •G cn M <br /> z o o CD <br /> o �. <br /> 7�`0 <br /> Signature of ner or Agent Date o C <br /> Remarks .. �..... .. .�! .. . L ram' .`2�1y! C .... ..... � X 0 <br /> m <br /> ��� <br /> ilCD <br /> �� .............. J..�.... ................................................ / :\ Loll <br /> NM" <br /> Inspection Date ....................................... ........................... 1�: o 0 0 o cn m <br /> ZoningAdmini ator :1 �: 0 0 0 0 O 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 he made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br /> 1'0 Inl onJ� �r fur se ��p0vc�l. � <br />