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Burnett County Office of Zoning Administri for o <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT 3 <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and <br /> " <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements o the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 a <br /> reg of the St to of Wisconsin. " a <br /> .................. ................................:................................................... ....... <br /> OWNER (plasm print) // CONTRACTOR or SURVEYOR or AGENT <br /> . .................... .................................................................................... <br /> ADDRESS DRESS lv� AD _ <br /> .............'...~. .....5.....i..7.... ... ................................................................................ ....... <br /> ADDRESS <br /> ADDRESS (�� <br /> ............ ...-....y .`.. .- '` ..................... . .................................................................................. ....... <br /> PHONE PHONE <br /> ........................................................................................... . ..........DR......ILL.....ER............................................................ ........ <br /> PLUMBER WELL <br /> v A <br /> .......................................... ....... <br /> ....................................................................... . ...... .. ........................... . <br /> ADDRESS ADDRES.. ..S » p V� <br /> ................ .. ................................................................................. ........ <br /> ........................... .............................................. . <br /> O �+ <br /> PHONE P.HONE P r :d <br /> DESCRIPTION 4. Sanitary Facilities: P 0 °^ S <br /> No. Bathrooms • ........ v <br /> ; <br /> 1. Work: 2. New BuildingDetails 'o <br /> No. Bedrooms <br /> New Building . ........ 3 <br /> ,,,,,,,--, Type of Construction: Septic Tank Size Gals. . ........ <br /> Addition ..X... ......................................rrJJ. ... .. :3 <br /> Sanitary Size . •. . ........ <br /> csc <br /> ........., ,r2Y..... ft. x ......... .. f[. 4a. Absorption Field Site: ' <br /> nj� <br /> Filling/Grading .......... Height............. Stories ...c3.`......... i <br /> SoilType ........................... ........ i r <br /> Moving .......... Area .......................................... o A <br /> Slop <br /> Mobile Home .......... Perc. .ate ......................... ......... <br /> Privy .......... 3. Use (describe -family <br /> Parc. Rate ......................... ......... m <br /> n <br /> Well .......... h e,garage, motel, etc.) <br /> Dry Well ......... `° i <br /> 'fir �s t-k ����.... Seepage Trench ...... o N <br /> Subdivision .......... i <br /> .................. <br /> Camping Unit Priv ...... 1 <br /> Y <br /> .......... ..�'................�V.Gf'.�........... Seepage Bed ,11 nn <br /> ---------------------------------------- --- <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. 9.1 <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is loc ted at Li ;2* <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the interse tion. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. O (� <br /> -----------�---------------------------------------- -- <br /> 5. Lote/ "I" � Fig. A. 6. Location: U•1' <br /> ............ ft. x rx(y6.• ft. . ............................... sq.ft. .................................................................... .......... o <br /> a <br /> Q1 : 0 <br /> N G O <br /> o Z <br /> ,a 9 <br /> ^L <br /> Z <br /> P Q: <br /> nd <br /> J <br /> m <br /> �1 <br /> M c M w m cDi cc <br /> �, <br /> M m -0 <br /> _. In <br /> � Na•`c ''—� nm as 9 <br /> Z Fp0 D <br /> 7 N d A <br /> o c o m <br /> a O <br /> m <br /> 0 <br /> ....... ... .. ... . ..... ........... ....... ........ .� .-.. .. P O <br /> M <br /> Signature Ow r or Agent Date <br /> N <br /> T; d <br /> Remarks <br /> � N <br /> ............................................................................................................................................................................... ........ NO <br /> O <br /> .......................................... ...... ...... <br /> . .............. O <br /> ....................... ......... <br /> N O N m <br /> .......Lj NON O <br /> Inspection Date ....................................... ......... ....trot................ ........ <br /> Zoning A" inistri for g g g g y <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities before constructio <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this a plication 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 t een 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 kPPROVED. <br />