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Burnett County Office of Zoning Administrator ' 0 1 z <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT h' 3 <br /> d 1+ 0 <br /> TO THE ZONING ADt�,IKISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as v <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. 3 a <br /> '+ a <br /> r H h O <br /> D..r .i.. . .. ............ .. . .. ........................... ' .. .. H <br /> v, <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT CDCL <br /> ...Rt a 1..a 9 <br /> ADDRESS ADDRESS <br /> .e..!.../.. . ..^^n;/Y...... 'rl.^.:......... .P.V.6.. ... .ADDRESS............................................................................ N G. <br /> ADDRESS J _ <br /> PH E PHONE <br /> ............ ................................................ .................................................................. <br /> PLUMBER WELL DRILLER <br /> Jill <br /> '\ v <br /> ADDRESS 'dJ <br /> ADDRESS CD o <br /> c < <br /> 0 <br /> PHONE 0 I- <br /> ................... <br /> PHONE ' <br /> DESCRIPTION z y 0 '6 <br /> 4. Sanitary Facilities: °f ° o <br /> 1. Work: 2. New Building Details No. Bathrooms <br /> o <br /> No. Bedrooms -. m <br /> New Building .•• Type o onstruction: v <br /> Addition ••.•••,•,• ........... ��h�+. -< Septic Tank Size Gals. <br /> �s } S� <br /> Sanitary Size ..s�...... ft. x ...t 1... ft. <br /> ... <br /> Filling „•,,..• Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Area Soil Type .................................... <br /> .................................. 0 <br /> GradingSlope .......................................... <br /> Mobile Home .......... 3. Use (describe exactly, famil Perc. Rate ................................... e, <br /> Privy .......... home,garage, motel, etc.) Dry Well .......... <br /> Well Seepage Trench <br /> ...................................... .......... . . <br /> Subdivision Privy a• �� <br /> ................................................... y <br /> -------------------------------------------------- Seepage Bed 1 I— SL :� '• <br /> Location of proposed structures and existing structures,well,sewage systems,roads,etc.,should be sketched in Fig. A. Include road <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING L. y. <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. v o• <br /> ------------------------------------------ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x ft. sq.ft. �: :411-• N <br /> (U i <br /> C <br /> m <br /> C" <br /> o <br /> n <br /> v <br /> 0 <br /> �►1 '' <br /> T v kip <br /> 8 Qyer M c r :o�c co <br /> CD CD Nan.< 'O_ � <br /> v <br /> z oo CD � � m <br /> o = � <br /> � 5 <br /> 7 -a z -9V <br /> ........... .. ....... .. . .. ........ .................................. <br /> Si ture of O ner or Agent Date ° C <br /> Remarks .........�`.. l�fJ................................................................................................................................................. -n m <br /> CD <br /> CD <br /> v <br /> ... .. . ...... ... .. <br /> ...... 7�w r�'.0 .. . .. ............................ ........................... <br /> /-� <br /> Inspection Date <br /> - `.. ....... LLo o 0 0 0 <br /> ..... . ...... ..... ............................. • Q oob ' <br /> ZoningAdmin' rator r< IJ a o 0 0 o 0 <br /> DOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> refore 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 /> ng until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> vith 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 />