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Burnett Cou;tty Office of Zoning Administrator TM o 0 <br /> ' APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3' o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as '< N M :\ <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 C de,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. a <br /> a � <br /> r.r..�..�.. .......L:......... .�...v. ..... ............. ..F.i.. .. 5. ..n.......... '. w1�..S... <br /> 6Wf (please print)A-4 <br /> II t / / ,,Q(� CONTRACTOR or SURVEYOR or AGENT 0 <br /> ...01. <br /> ........A-4.. ?..b.a.r........../f................. .......................................................................................... d 0 a <br /> ADDR.-E�S•-S Q f ADDRESS <br /> $...1...-.........1....a.ti...L..... .rt.........Ss �. ............................................................................................ is <br /> ADDRESS ADDRESS <br /> PHOPHONE ;;q <br /> )1.0 <br /> ......................................... EV.1 <br /> PLU ER WELL DRILLER <br /> ........................................................................................... ..A...... 'E'S"S.............................................................................. � <br /> ADDRESS DDR. ESW 0 o <br /> * < d <br /> ....... o ,•: <br /> PHONE PHONE Z r- <br /> 4. <br /> :C <br /> DESCRIPTION 4. Sanitary Facilities: ( ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms ;� o <br /> ........ i s <br /> New Building . Typeyf Construction: No. Bedrooms a2. � <br /> r y <br /> Addition Septic Tank Size Gals. <br /> Sanitary .. Size ... .... ft.x ft. <br /> Filling Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Area .. Rl 1L0..:£........... Soil TYpe .................................... r <br /> ... ..... <br /> Grading .......... Slope .......................................... <br /> Mobile Home 3. Use (describe exact) 1 -fa Pere. Rate ....... <br /> Privy home,garage,motel, a .) Dry Well .......... <br /> Well „}�,,, Seepage Trench .......... ki <br /> ....... <br /> Subdivision Privy <br /> Seepage Bed l-. ,X35/ �0 <br /> ---------------------------------------------------------------------- 1 N <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road kit 6 <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- U a <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 /> L---------------------------------------------------------------------- i <br /> 5. Lo Size: Fig. A. 6. Location: <br /> �Od ft. x .. .� ft. — ............................... sq.ft. O D <br /> r :N N <br /> : I c' <br /> N O <br /> O = <br /> _ <br /> O <br /> Nr <br /> o <br /> TA <br /> Z <br /> :o <br /> o <br /> C 0 °gym ooz <br /> m. Naa< � o-� <br /> o CP <, C: <br /> O N N : : •G t� C m <br /> Z OO m <br /> o <br /> o ' <br /> ofa <br /> . .. .......................... .... . . .................. po c <br /> Signa... <br /> tur.e of O ner or Agent Date <br /> Well must be at least 50 feet from drainfield. . -n x G <br /> Remarks ......................................................................................................................................................................... i <br /> �Z� l�f 7i <br /> m • <br /> ...............�..... .. . ... .........`pi� ......................................................................................... ............................ <br /> S <br /> �..... <br /> �- r� t. ' .................... ........................... ......................................... rii <br /> ....... ti . <br /> // o T <br /> Inspection Date .l`................................... a �z •• :0: o 0 0 0 0 o m <br /> ....... . . <br /> Zoning Administrat ti <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. 111 <br />