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a: <br /> Burnett County Office of Zoning Administrator C _ o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ;; 3 o <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as '< Z, -« V <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land UseCDc <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 CD <br /> r: 'a <br /> ev .. <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT a M <br /> z.....1 p.. ....3... - '........ ^ <br /> ....................... ......................................................................................... <br /> ADDRESS ADDRESS ^, <br /> I... .. .................... ......................................................................................... <br /> ADDRESS ADDRESS <br /> 'r8' :-.. ..� .. ... <br /> ' <br /> PHONE PHONE <br /> %t, <br /> i <br /> W .... <br /> E D RI LL ..................................................................... : w <br /> PLUMBER LL ER.. <br /> •0 � V v <br /> ADDRESS ADDRESS <br /> CD <br /> r+ < <br /> .......... <br /> PHONE PHONE <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> 1. Work: 2. New Building Details No. Bathrooms <br /> o <br /> New Building Type of Construction: No. Bedrooms <br /> .......... <br /> Addition ! ...... Septic Tank Size Gals. .......... , <br /> y .......... <br /> Sanitary „•, Size ....1. ft. x .. ..` .. ft. <br /> Filling ...•...... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Type Soil T e .................................... �} <br /> .......... Area ........................................... r <br /> p ......................................... <br /> Grading •••„••••_ Sloe e <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family Perc. Rate .................................... <br /> Privy Dry Well U <br /> .......... home,garage, motel etc.) 1 <br /> Well „•,••• Seepage Trench <br /> ..C. . ,( <br /> Subdivision ......•••• D .••• Privy <br /> 1.�. ...F •• Seepage Bed <br /> ----------------------------------- r�� ------------------------'=_ <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road <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- 4� �- <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 /> --------------------------------------- --------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. - ............................... sq.ft. ............................................................................... <br /> �.. N <br /> CD <br /> o =. <br /> o <br /> 0 <br /> Or <br /> :w <br /> f � o <br /> 30 <br /> En 'n z <br /> jc ( m �CD C <br /> 2:CL << <br /> H w'a <br /> 0 0• y . < m <br /> 3m : <br /> - <br /> ���P A a <br /> .. / <br /> .............. ..................fir'. - � 8'3. N� c <br /> Signature of Owner gent Date -• <br /> X <br /> Remarks ......................................................................................................................................................................... m <br /> m <br /> ........................................................................................................................................................................................ — <br /> '� n <br /> ;p <br /> .......................................................................................................... .................... .... . .................................... <br /> . ........... .... ... . ... ......... <br /> N <br /> Inspection Date ....................................... l??.?t1,0. .... .... .............. .............. Q <br /> UUU 00000cnm <br /> Zoning Admin tr Kr o 0 0 0 0 o m <br /> 000000cn <br /> TOTE: 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 /> its application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> ig until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> ,ith 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 />