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Burnett County Office of Zoning Administrator iv - 0 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 Z7 <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m <br /> Ordinance, Sanitation Code,and with all they applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 CL <br /> ... .............................. ..............�.......I............ ............................................................................................ <br /> WNER Ipl se i CONTRACTOR or SURVEYOR or AGENT a <br /> .r............ A.e'....................... ............................................................................................ <br /> ADDRESS ADDRESS <br /> ADDRESS ADDRESS —/ <br /> . . . . ................................................................................. <br /> PHOIJE PHONE �� :o�` : 3 <br /> ;n <br /> PLMBER WELL DRILLER <br /> .. ............................................................................ <br /> . ~ <br /> O <br /> ADDRESS AD.....DRES......S.. :g tt m 0 <br /> N <br /> 0 o <br /> .............................................. .. ................................................................................... o' <br /> PHONE PHONE.. Z y r <br /> DESCRIPTION 4. Sanitary Facilities: , o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details "" ' 0 24 <br /> New Building .......... Type of Construct' n:, No. Bedrooms ... <br /> Addition + •,K/,1 y� Septic Tank Size Gals. <br /> •.....•.••.. _ G <br /> 3 <br /> Sanitary ... Size .............. ft. x ft. <br /> FillingHeight............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area Soil Type .................................... o <br /> GradingSlope .......................................... <br /> Mobile Home .......... 3. Use (describe exactly, =family Perc. Rate ................................... irk <br /> Privy home,garage, motel, etc.? Dry Well .......... <br /> :— <br /> Well Seepage Trench .......... 4 <br /> .......... .................................................... <br /> Privy <br /> — Subdivision ......I... .................................................... <br /> Seepage Bed <br /> ------------------------------------------------------------- {� <br /> Location of proposed structures and existing structures,well, sewage systems, roads,etc., should be sketched in Fig. A. Include road c <br /> o' <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- o- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING �.��• <br /> N A <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. :3 ;f <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. C> <br /> ................ ft. x .............. ft. — ............................... sq.ft. v i. <br /> r <br /> (� N <br /> l0 <br /> N $✓ O <br /> O 7 <br /> V O <br /> -90 --I <br /> SCJ 'A� ? <br /> T <br /> Z <br /> O <br /> 7J <br /> d <br /> m <br /> O <br /> cn <br /> � r- -V:Ev>m c <br /> ry O Nam O < — <br /> -0 onM <br /> C:> Ln. <br /> Z o o <br /> O <br /> N � <br /> o m <br /> Signature of ner or Agent Date 70 <br /> X m <br /> Remarks ............................................................................................................................................................................ <br /> [1� <br /> ........................................................................................................................................................................................... <br /> ... ................................................................................................................................................................................... <br /> oInspection Date .................................... ............. m <br /> Zoning AdminiFa <br /> o 0 0 o CA <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 riot 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 />