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Burnett County Office of Zoning Administrator fC c <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 + i d <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and <br /> regulations of the State of Wisconsin. <br /> ... 44�............................................. ........./J s.......... ................................ g <br /> OWNER (please print) CON ACTOR or SURVEYOR or AGENT <br /> .....F1.2........... <br /> / oso�rJ......Lti .............. ......%�j..' `.. .........../. � ..a3...... �-� - <br /> 0 <br /> :U? <br /> ADDRESS ADDRESS °1. <br /> Ty...........��.:................................... ............................................................................................ � s>J 71ADDRESS ADDRESS <br /> 6�D.6. ....................... ... ........................................................................................ Vi <br /> PHONE <br /> PHONE <br /> \\ d i^ <br /> PLUMBER . ...........R'*i'L ......................................................................... <br /> WELL DRILLER <br /> o f <br /> :S <br /> A....... .RES... ........................................... ... <br /> .................. ................ <br /> ADDRESS DDS <br /> 'm0 <br /> °0 <br /> ............................................................................................ N :Ir <br /> PHONE PHONE Z � <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° '\N <br /> 1. Work: 2. New Building Details No. Bathrooms — <br /> New BuildingNo. Bedrooms .......... ° <br /> .......... <br /> .../l.. Type of Construction: <br /> Addition ...... Septic Tank Size Gals. ....-... <br /> ................................................ .. <br /> Sanitary ' <br /> .......... Size ..Z.z.... ft. x ...Z..`:�.. ft. .......... <br /> Filling/Grading .......... Height...Q........ Stories ....!......... 4a. Absorption Field Site: <br /> Moving Area .......s2- SCJ Pz'......... Soil Type ..........................I......... r i <br /> .......... ....... ..... . ...... <br /> o <br /> Mobilo Home .......... Slope .......................................... <br /> Privy Perc. Rate ................................... m <br /> .......... 3. Use (describe exactly, -family <br /> Well .......... home, arage, motel,etc.) Dry Well .......... m <br /> Subdivision •„•••„•, 2 f Seepage Trench Z <br /> ....... 1...�.'...:7.�................ I......... O <br /> Camping Unit .......... Privy .... ..... <br /> .................................................... Seepage Bed <br /> Location of proposed structures and existing structures well sewage systems, roads, etc. should be sketched in Fig�A <br /> Include road setback,side and backyard dimension and location and setback from all bodies of water. If property is located at L <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. "1 0 <br /> ------------ ______ _ — �. <br /> 5 .Lot Size: <br /> Fig. A. 6. Location <br /> ................ ft. x .............. ft. — sq.ft. ............................................................................... <br /> LOT LIN[ <br /> n <br /> N O <br /> O 7 <br /> � C <br /> 0 <br /> - O <br /> V <br /> z c <br /> L i N E <br /> `✓ �— €� <br /> at Nvw r Dto to -0 <br /> _7V 1 A �a Z 0” n m c c m <br /> w m > <br /> Nom . qa ' <br /> ......................................7 <br /> n : m <br /> Signature of Owner or Agent Date 'o <br /> Remarks M <br /> T: <br /> m <br /> m •• <br /> w A <br /> ........................................................................................................ ...... .................... .. . ........................ .......... <br /> Inspection Date ....................................... ...,.. .... .... ... ".”.i.4.4.`.�!:!:!.Y............... ren o u, <br /> /I Zoning <br /> wry) SSS <br /> Administr r 0 0 <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this application 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 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 APPROVED. <br />