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Burnett County - Office of Zoning Administrator W CD o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as 0 ? G <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m c �► <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. I a t'� <br /> ........... A..".. ...F...J� .. � eu- ..,. fi..a.�1........... ..........&t-.. .................................................................. <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT 0 "' m <br /> a. <br /> ............... o.-.....l�S f�...................... <br /> ADDRESS ADDRESS <br /> ADDRESS ADDRESS ice. <br /> `f�.3...-.. ..3.. "..................................... ............................................................................................ <br /> PHONE ,�/ PHONE �O,v <br /> .........!VIP..?!l.............................................. ............................................................................................ <br /> X <br /> PLUMBER WELL DRILLER <br /> .............................................................................. ........................................................................................... <br /> CD 0 <br /> ADDRESS ADDRESS <br /> . : <br /> ..................................................Y....................................... J o <br /> PHONE PHONE v z y <br /> DESCRIPTION 0 <br /> 4. Sanitary Facilities: P ° o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details 0 <br /> o <br /> New BuildingT No. Bedrooms z <br /> .......... Type of Construction: � <br /> Addition lttn d Septic Tank Size Gals. �y <br /> v............f r..4.rn ...... lr <br /> Sanitary .......... Size ......1. ft. x ......1.-��. ft. <br /> Filling g ' / 4a. Absorption Field Site: <br /> .......... Hei ht......I...... Stories ...... <br /> Moving Area ........ Soil Type .................................... i '- o <br /> Grading / Slope .......................................... icy <br /> .......... <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Privy .....•.... home,garage, motel, etc.) Dry Well .......... tJJ b' <br /> Well Seepage Trench .......... <br /> ....................................... . j <br /> Subdivision � o e ff C y <br /> ..✓..41.... S. ...... ... Privy (n , <br /> Seepage Bed <br /> -- ——— ——— ——————————— ------------------------------ 0 'a <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road 4r,: <br /> setback, 0- <br /> side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- 'S �` �. _°- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING r� :' <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. W N <br /> o' <br /> ---------------- ------------- <br /> ---- ----------- ------ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — .... sq.ft. ....4&.10J JQ4' i.e:t?t, <br /> Ual ��� rake » N � <br /> 0 0 <br /> QM <br /> n 0 <br /> 6 <br /> pr©pose_d '�v %r <br /> �C z �°�► <br /> o <br /> �+V m <br /> V <br /> eQ ?� <br /> C/) C/)tL-:�' <br /> Z <br /> CD C: CD <br /> 2, NQD_�-0 V7 < CffW * m <br /> Z o° fD `D 70 <br /> o <br /> ... :. . <br /> 93 <br /> Signature of Owner or Agent Date <br /> • X 70 <br /> Remarks .................................................:....................................................................................................................... - M <br /> CD <br /> ....... .... <br /> .................................................................................................... ............... ......... <br /> : �^ 0000ll o 1�1v, m <br /> InspectionDate ....................................... .:....._r::........._._... g ......' ................................ b b o b b b m <br /> Zonin Adm strator 0000000 <br /> VOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> )efore 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 /> Nith 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 />