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Bureett County- ,AJ 7�i //�� Office of Zoning Administrator v CD o o J <br /> ,r APPLICATION FOR SANITARY — LAND'USE BUILDING PERMIT � 3. <br /> o OTO 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 m e �l <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> _. <br /> h <br /> o <br /> 6W"� R (please grin ) s��6 J CONTRACTOR or SURVEYOR or AGENT Q <br /> P.............................. ID <br /> ......................................................................................... \� <br /> ADDRESS ADDRESS * ' <br /> ADDRESS ADDRESS <br /> PHONE PHONE <br /> � W -M 6A" <br /> PLUMBER........................................................... � ...... . <br /> . ................................................................ .. <br /> WELL DRILLER <br /> ��.. ..1.s....... '.1?.�.�r!!?..r.. v..!�...... ........... <br /> ADDRESS ADDRESS :N CD o <br /> o' �+ <br /> PHONE PHONE z <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms_ <br /> 2. New Building Details ""'� �• o <br /> New Building ......�...1 Type of Construction: No. Bedrooms .......... <br /> Addition Septic Tank Size Gals. l..©P..a� ` :CA <br /> .......... <br /> Sanitary ...`.�. Size .............. ft. x .............. ft. <br /> Filling .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Soil Type .................................... o <br /> Area ........................................... <br /> Grading .......... Slope ..........1.. 4..... ... .. .P '+ <br /> Mobile Home •......... 3. Use (describe exactly, 1 -family Perc. Rate ........-.. .................. <br /> Privy .......... home,garage, motel, etc.) Dry Well <br /> ......... <br /> Well .......... ..... <br /> Subdivision ....�it� Seepage Trench <br /> / .................... Privy <br /> .......... .................................................... <br /> Seepage Bed — <br /> ---------------------------------------------------------------------- I <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc., should be sketched in Fig. A. Include road s 4 <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- S4.1 0_ CD <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING I y• <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. C� <br /> ................ ft. x .............. ft. — ............................... sq. ft. <br /> �da N <br /> O <br /> 7 0 <br /> 7 3 <br /> (� N <br /> 0 � <br /> N <br /> rF <br /> •V <br /> -n <br /> z <br /> o � <br /> c: <br /> M c/)r- :F <br /> CD Cv �.V <br /> L R) rD <br /> N : <br /> Z 03 <br /> ° CD <br /> N <br /> O <br /> :J r <br /> ^) C <br /> Signature of Ow r or Agent Date <br /> -n X r <br /> CD <br /> Remarks . .1.� `" Z `- �j'„ m 'C <br /> ....................................................................................................................... ru, <br /> ............... . .............................. ........ :.......................................................................................................... N <br /> r.............. . ..... ................... � . <br /> . ... .. . ... . . <br /> Inspection Date a ........ ................. r 0 0 0 o <br /> Zoning Admin' rator <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 />