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Burnett County Office of Zoning Administrator 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 ; '' :& <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Usem m :� <br /> Ordinance, Sanitation Code,and with all other applicable County Ordin ces and the laws and regulations of the State of Wisconsin. 3 0. <br /> -�.................�% ................................................... . ... . ... . ... ................................. C <br /> OWNER (please print) CON`TR <br /> OR <br /> or <br /> SURVEYOR or AGENT a , <br /> ADDRESS............................................................................ ..v .4�..1. .../.C].U. :.`7V................................................ .O: <br /> `��P ... ....t5.,r� 7.Z...................................... <br /> ........................................................................................... -..1.. .... ....... <br /> ADDRESS ADDRESS <br /> ........................................................................................... . .......................................................................................... ; <br /> PHONE PHONE <br /> . ..................................................................................... pper,,,, <br /> ........................................................................................... . . .WELL DRILLER <br /> PLUMBER <br /> i <br /> .......... <br /> ........................................................................................... . ................................................................................ _. <br /> ADDRESS ADDRESS n o <br /> r. <br /> ........................................................................................... . ................................................. ....................................... � o <br /> PHONE PHONE Z r <br /> DESCRIPTION 4. SanitaryFacilities: ° o c <br /> No. Bathrooms """" <br /> 1. Work: 2. New Building Details " o <br /> New Building .......... Type of Construction: No. Bedrooms .......... <br /> Addition .................................................... Septic Tank Size Gals. .......... i <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Area ......................................... Soil Type .................................... <br /> .......... .r <br /> o i <br /> Mobile Home .......... Slope .......................................... ,* <br /> Privy .......... 3. Use (describe exactly, 1 -family Pere. Rate ................................... <br /> Well .......... <br /> Well .......... home,garage, motel, etc.) Dry moi✓ ; <br /> Subdivision Seepage Trench .......... <br /> �.... .................................................... <br /> Camping Unit Privy <br /> .......... .................................................... <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 or <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- 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 /> ____________________________________ <br /> 5. Lot Size: Fig. A. 6. Location: ( J <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... d a <br /> V ` � <br /> 7� o Q 3D/ 3 ° Z [� <br /> 0 <br /> 0 <br /> f <br /> m <br /> Z <br /> ' o <br /> d <br /> 61, <br /> M N -o :k d W Z <br /> ng <br /> N m D <br /> on < wC <br /> - m <br /> Z o o a 37 <br /> o n ° 3 <br /> F» - <br /> kk�� <br /> :! <br /> /D- y�-r m <br /> p <br /> ........................................................................... ......... ......................... o C <br /> Signature of Owner or Agent Date ' ' <br /> Remarks ......................................................................................................................................................................... <br /> m m <br /> ss <br /> ........................................................................................................ ................moi.....-t/.�.. ................. g T <br /> Inspection Date ....................................... �11'(:��/..:....7................. ......Y�...�............... E 2 g ren o U o U m <br /> ZoningAdm�or 1 888888rn <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 I e made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />