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WS'CrJ s12 6 ` T)r=c»;,�� . <br /> r <br /> Burnett County Office of Zoning Administrator Iw o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT <br /> 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described nd q o <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of he n <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws End <br /> regulations of the State of Wisconsin. (� (, 3• <br /> ........ .�'lYkf.�t1 .....�LSo.!. ..............................I....... r t ' ...�. ..1� :1........................................ .... £ A { <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT $ <br /> R.i.... ...... �� ...(.( . . ..it.o ..h <br /> ..................................................... .... <br /> ADDRESS f ADDRESS / •+ i <br /> ...... .0............................. .......... . ....aN �tnay..t...:...`.5....-5.`.. .................... <br /> ADDRESS ADDRESS ) v.. .j <br /> ' o- �13� w ,f t1 ion (� � <br /> PHONE......................................�........................................ .PHONE......... .............�............................................ . <br /> ................. . ...................................................I <br /> PLUMBER WELL DRILLER <br /> ADDRESS ADDRESSn 0 <br /> n o 1� <br /> ^. < <br /> ;fn <br /> PHONE PHONE Z <br /> DESCRIPTION 4. Sanitary Facilities: P o <br /> 01 <br /> 1. Work: No. Bathrooms .... ..... <br /> 2. New Building Details 'o <br /> New Building ....!y. Type of nstruction: No. Bedrooms .... ..... :( <br /> „�1{'.,,„� Septic Tank Size Gals. .... ..... � <br /> Addition ..... .....W.............. J <br /> ... <br /> Sanitary .......... Size ..A.;...... ft. x <br /> Filling/Grading g C-� 4a. Absorption Field Site: <br /> .......... Height Storlpp��s ...l........... <br /> Moving .......... Area ......i3�2...S.S.f:.................. Soil Type .............................. ..... <br /> o <br /> Mobile Home Slope .................................... ..... <br /> .......... <br /> m i7 <br /> Privy .......... 3. Use (describe exactly,'1 -family Perc. Rate ............................. ..... <br /> Well home,garage, motel,etc.) Dry Well <br /> .......... �C <br /> Subdivision „ .,,,,,,, ,.,....(..,{ '1 �e.ra Seepage Trench .... ..... <br /> ar ,.7.. .. ..................... <br /> --Camping Unit— Privy .... ..... <br /> Seepage Bed .... ..... �1�� ? <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig A. o _ <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is locate at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersecti n. Iln, <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. O o <br /> -------------------------------------------------------------------- — E <br /> 5. Lot Size: Fig. A. 6. Location: . <br /> ...�`”: ft. x ft. — ............................... sq.ft. .......W ........................... ...... <br /> 41 <br /> / o f ?. <br /> I ` <br /> O \ <br /> lE �q <br /> '!o <br /> 0 v <br /> O <br /> 7 m <br /> M <br /> c] i m 0cm cm -0 <br /> m <br /> dCw > > 3 <br /> m <br /> rn <br /> n : y <br /> n ? vSignature of OWner or Age/t Date o <br /> Remarks ' v <br /> m •• <br /> u <br /> a : $ <br /> Inspection Date 4VIt �1 /�. , , N n <br /> ....................................... .... ............ .............. .... ................... .. vt . �noo �n m <br /> Zonin A inistrator a8 8 8 8 8 8 y <br /> NOTE: A preliminary site inspection must be made and site ap ro at granted on all structures involving sanitary fact ities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this appli ation 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 ors ecifications 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 />