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Burnett County Office of Zoning Administrator g' n 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> o :\ <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 Use m C <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. o. : <br /> -S' ....................................... .... . r .... ... C _ o <br /> a <br /> m <br /> OWNER (please print) CTRACTOR or SU R4V EYOR or AGENT <br /> /7• ..1.....� ?.dX....� �3.... a <br /> ADDRESS ADDRESS <br /> ADDRESS............................................................................ w✓.RESS.......... ..... <br /> .�...* ........... <br /> ..�..1 .� ...... ............... <br /> A D <br /> ........... <br /> ........................................................................................... . . . . ..PHONE...................................................................... <br /> PHONE. ............................................................................... <br /> PLUMBER WELL DRILLER <br /> O � <br /> ADDRESS............................................................................ .ADDRESS............................................................................ m 0 <br /> n o 0 <br /> ........................................................................................... .......... .................................................................... <br /> ............ <br /> PHONE PHONE.. Z H � <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathroomso <br /> .......... <br /> New Building .......... Type of Construction: No. Bedrooms .......... <br /> Addition .......... .................................................... Septic Tank Size Gals. .......... <br /> Sanitary Size ft. x ft. .. ••• ••• <br /> Filling/Grading ,•........ Height.,..... ... Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area Soil Type .................................... r <br /> Mobile Home Slope .......................................... : 0 <br /> Priv Perc. Rate ................................... <br /> y .......... 3. Use (describe exactly, 1 -family <br /> Well •..•.•.... home,garage, motel, etc.) Dry Well .......... i <br /> subdivision Seepage Trench .......... <br /> .................................... ............... <br /> Camping Unit ..... Privy .......... <br /> ..... .................................................... <br /> Seepage Bed .......... <br /> -- Or,Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig. A. Include road Q <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. p <br /> --------------------- ------------------- ---------------------------- E <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... s9.ft. ............................................................................... <br /> M <br /> 1° ltJ3 0 <br /> o <br /> L T <br /> m <br /> m <br /> 7 <br /> m <br /> :t <br /> �7 <br /> C m 17 N M 2 <br /> r � <br /> N <br /> Ul NC �➢ C M <br /> m — m <br /> Z O o' D n <br /> p o o <br /> � o <br /> D <br /> m <br /> Sig" .......................r' 'o-r........................................ ........................ . C <br /> Signature of Owner or Agent Date � — <br /> X <br /> T <br /> Remarks ......................................................................... : m <br /> .:.............................................................................................. m :�i O <br /> m <br /> kAA 11 <br /> ........................................................................................................ . . ......................................................................... . . <br /> Inspection Date ....................................... lzrzG!!./...:..... . . ` IrTf1T <br /> . . ...................... O. O U O N O N <br /> ZoningAdr �J 0 888888y <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. <br />