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,,.•-�, <br /> Burnett-Cc3un�y Office of Zoning Administrator W CD o 0C�"►f`." <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. o v <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as ; :J <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use CT) <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 o.. L1� <br /> c,64: i��oYl. �.. '. *U................ ....... a.l�/./q... O <br /> O NER (please print) CONTRACTOR or SURVEYOR or AGENT aCD <br /> 63.I... .A . ale ....Avv............................................ ........................................................................... <br /> ADDRESS ADDRESS •* <br /> r. <br /> ..........5,5 /..!.z--..................... <br /> ADDRESS ADDRESS O� ; <br /> PHONE PHONE <br /> ........ ........... <br /> PLUMBER WELL D..RILLER..... <br /> p <br /> ADDRESS ADDRESS m 1� <br /> h 0 <br /> o' ,* <br /> PHONE PHONE <br /> z y r <br /> DESCRIPTION 4. Sanitary Facilities: o ° <br /> 1. Work: No. Bathrooms T <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 Area Soil Type .................................... r- <br /> .......................................... <br /> o <br /> Slopeope .................................... ..... ; <br /> .......... . . <br /> Mobile Home Perc. Rate ................................... <br /> .......... 3. Use (describe exactly, 1 -family � <br /> Privy ., home,garage,motel, etc.) Dry Well .......... i <br /> Well Seepage Trench .......... 4,- <br /> .......... .................................................... <br /> �i <br /> Subdivision Privy <br /> Seepage Bed .......... J <br /> —————————————————————————————————————————————————————————————————————— <br /> N <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road Q c <br /> s <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- Q <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. o' <br /> ------------------------------------- ---------------------------- C : <br /> 5. Lot Size: Fig. A. 6. Lo at'Qn: _ <br /> ....... ft. x ..qs ?.. ft. — I.Q .fSQ�?............. s ft. ..`.1'.3CS......Xo(..S aa4 .� .:.... :3 <br /> q. ,. �5..... <br /> rLrj' ,tF Gov, c,3� q 7-404-9. N <br /> C <br /> N `\ O' <br /> o 4 � <br /> 0 <br /> h :-4C' <br /> n T <br /> \ <br /> per, S CD <br /> : o <br /> Lq/ce <br /> (Y -700 _ CD <br /> S DSO' 1 te/ <br /> 3 <br /> v' r � �rnmz <br /> A 6 3 C * <br /> T. N Q a _ rt Q <br /> -O U7 < <br /> z oo.y m <br /> o > >. <br /> 0 <br /> CD M <br /> ..................... .... 41 ........... w o c <br /> Si�nature of caner or Agent Date h <br /> X <br /> Remarks -n M <br /> CD <br /> cs� <br /> ......................................................I.......................... .......................... .. ............................................. <br /> IN <br /> Inspection Date :��?�. �rr�i <br /> .J.......................... : : . 0 0 0 0 o m m <br /> trator o 0 0 0 0 0 cn <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 />