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Burnett County Office of Zoning Administrator 3 C 0 0 <br /> APPLACAVON FOR SANITARY — LAND USE — BUILDING PERMIT 3. o :O <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as ; Iv <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m += 1v <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 n :� <br /> f•� ...... <br /> ....�.P.�..�?11..�...1�..e..(. ...................... �.�/< ... �� �..►..'...>�.�`'!r1... c <br /> H O <br /> OWNER ( se print) C RACTOR or SURVEYOR or A T a `� <br /> ��.. ..�. ........`5 4.. .....................e......�.�....� ............................................................................................ <br /> A DRJS s ADDRESS O1 <br /> .f�. .......................................... ............................................................................................ <br /> ADDRESS ADDRESS EN . <br /> ........ ................................................. ............................................................................... <br /> ............. <br /> P E PHONE � ''O (�,• <br /> ..... .......... .......................................................... <br /> PL MBER WELL DRILLER ;T� <br /> .................................................................. .. ...................................................................................... <br /> ADDRESS ADDRESS... ? CD 0 3 <br /> ct < <br /> :o o ,+ <br /> PHONE PHONE z �„ r <br /> DESCRIPTION 4. Sanitary Facilities: o ° <br /> 1. Work: 2. New Building Details No. Bathrooms .......... o :: <br /> X, No. Bedrooms ....0— <br /> New Building .......... Typ f Construction: CD <br /> Addition ,. . .... !^o.m,�......... ,, Septic Tank Size Gals. <br /> .... ... .. <br /> Sanitary ....,)C... Size ..*`j.a••... ft. x . ...�.,. ft. ......•••• <br /> Filling .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Area Soil Type .................................... `• o <br /> .......................................... <br /> Grading Slope .......................................... <br /> Mobile Home .......... 3. Use (describe exactly, family Perc. Rate ................................... <br /> Privy home,garage, motel, etc. Dry Well <br /> Well Seepage Trench .......... <br /> .... <br /> — Subdivision Privy <br /> -------------------------------------- Seepage Bed <br /> ----------- N 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 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. lr� :�0 <br /> ---------------------------------- ----------------------------------- W 61 <br /> 5. Lot Size: Fig A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... <br /> i <br /> O C <br /> 00 O <br /> No O <br /> O <br /> S <br /> 'n <br /> CD <br /> CD <br /> G7 <br /> 3 <br /> CD <br /> QC '4 <br /> Cn v <br /> C v c co <br /> U_ Z < <br /> -a <br /> z o o' m �°—i7m0 <br /> isa <br /> `a3 -,73 � �_ p <br /> :..... ...._... ... . .................................. '�j o _ <br /> Sipaiof Owner or/nt Date9 X 70 <br /> ............................................................................................................................................. „ m <br /> Remarks .........................:. co p <br /> C <br /> u <br /> ......................................................................................................... ............. ... ....... ................................. <br /> 000v' o <br /> InspectionDate ....................................... f....:.... ......... ............ o 0 <br /> Zoning Admi istrator � o 0 0 0 <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 /> 'Ad saw 7.�,� -,�-& moo& 3(' (/0F cy,3) <br />