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Burnett County Office of Zoning Administrator Iv c <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT 3. <br /> I , <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and �2 p <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m C `• <br /> Burnett County Land Use Ordinance, Sanitation Code, and with a <br /> g II Pther applicable County Ordinances and the laws and <br /> re 3 <br /> ulaI ions of the State of isconsin. / : — i <br /> ........................................ .....�i t ... % mm <br /> t I �, �. <br /> _:.. <br /> OWNER (plea print) CONTRACTOR or SURVEYOR or AGENT' <br /> ADDRESS ADDRESS <br /> ADDRESSADDRESS ' <br /> . .._....(......:...: .....:..::.�..>.:. :"................... <br /> ........... S <br /> PHONE PHONE <br /> .......... <br /> ........................................................................................... . . . ........................................................................... <br /> PLUMBER WELLDR I LLER . <br /> ADDRESS ADDRESS m <br /> n 0 0 <br /> ........................................................................................... ............................................................................................ O .i <br /> PHONE PHONE Z <br /> '�. <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms ' <br /> 2. New Building Details ••• o <br /> New Building .......... Type of Construction: No. Bedrooms .......... <br /> AdditionSeptic Tank Size Gals. .......... <br /> .......... .................................................... ••� <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... i <br /> Fining/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... Soil Type .................................... <br /> Mobile Home Slope SloPe .......................................... o <br /> m i <br /> Privy ,,,,,,,,,, 3. Use (describe exactly,'1 -family Perc. Rate ................................... o p <br /> Well ... home,garage, motel,etc.) Dry Well .......... m <br /> �/ Seepage Trench <br /> Subdivision j��.. 9 .......... o, - - <br /> .....................I.............................. <br /> Camping Unit ,,........ <br /> Privy ..........�I) <br /> Seepage Bed <br /> ............ <br /> ---------------------------------------------------------------------- <br /> Location of proposed structures and existing structures well sewage systems, roads, etc., should be sketched in Fig. A. c <br /> Include road setback,side and backyard dimension and location and setback from all bodies of water. If property is located at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. <- <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> --___ _ ____ ----------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location:...............................................................��' ' <br /> ................ ft. x .............. ft. - sq.ft. ............... <br /> v i <br /> 0 <br /> a <br /> / F o <br /> 0 <br /> m <br /> Z -- <br /> O <br /> 9 <br /> W <br /> 7 <br /> ao <br /> //�� N <br /> OMUr//fe <br /> C, r <br /> See M,nufe� a May g-) mee-7i"nq <br /> (l U ) n\� mrDwwrn <br /> m i� r > > 0 m <br /> -� am aa9 <br /> O m < w O b m <br /> O N <br /> Y y n y <br /> ............................. ` x A . m <br /> ..igna ..........gent ...................................... /' <br /> Signature of Owner or Agent Date i�_ o <br /> w <br /> Remarks ......................................................................................................................................................................... m._ <br /> m •• <br /> ;i <br /> g g <br /> m <br /> Inspection Date ....................................... r,.�ka. ..✓-:). L.. ... .C>f:n .. t�-rli....., .. . cn <n )n o o cn m <br /> Zoning Administrator (A <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this application before a permit will <br /> be issued. Do not purchase or install a septic tank, do any plumbing or start any building until a permit has been issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />