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<br /> Burnett County Office of Zoning Administrator �n - 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
<br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use C \ ;�
<br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin.
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<br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT o.
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<br /> ADDRESS ADDRESS
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<br /> ADDRESS
<br /> ADDRESS .•�
<br /> 67�Ol ..
<br /> PHONE PHONE
<br /> PLUMBER WELLDRILLER
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<br /> ADDRESS ADDRSS
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<br /> PHONE PHONE Z H r
<br /> DESCRIPTION 4. Sanitary Facilities: / ° o °
<br /> 1. Work: 2. New Building Details No. Bathroomsp
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<br /> New Building ..., Type of Construction: No. Bedrooms ....�.. M
<br /> Addition ,,,,�(,,, Septic Tank Size Gals. 19921111:7
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<br /> Sanitary .......... Size ........ .......... :n
<br /> .. ft. x ....�. ft. .o
<br /> Filling/Grading „ ,,,, Height............. Stories ..../.......... 4a. Absorption Field Site: 3
<br /> MovingSoil Type ....................................
<br /> .......... Area ...........................................
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<br /> Mobile Home .......... Slope ..........................................
<br /> Privy Perc. Rate ...................................
<br /> ....:..... 3. Use (describe exactly, 1 �family
<br /> Well ,...,,.,,, home,garage, motel,etc.I Dry Well .......... ft
<br /> Subdivision ,,,, ,,,,, -S O-Lata-nJ firr.C�Seeo Seepage Trench ..........
<br /> r�A x Priv ..........
<br /> CampingUnit .......... ....14�.'................ .................. y
<br /> Seepage Bed
<br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road 1 e
<br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- C a
<br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING ” c
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<br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. H o'
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<br /> 5. L..4,.rg.4 .. � Fig. A. 6. Locati n: / :
<br /> ...a7. .... ft. x ..�..QQ ft. — ............................... sq. ft. ........ .QT..�.�......... �. ..�........ E E"`
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<br /> Signature of ner or Agent Date ° C
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<br /> Remark . . . ...................................................................................................................................................... m
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<br /> Inspection Date ....................................... '.,�,: . ... i Cn' a o �i o a m
<br /> Zministrotor...................... 8 8 8 8 8 8 y
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<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 fie made without approval of the Zoning Administrator.
<br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED.
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