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Burnett County Office of Zoning Administrator ,V' - o o <br /> '- <br /> ' APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT a' 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 Use m c <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 p. ,1 <br /> H <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT <br /> 4-59 R : <br /> ADDS................................... ......... ......................... .ADDRESS............................................................................ <br /> .............................................s ...... . <br /> ADDRE _ ADDRESS <br /> ............ .....3. .. .7........................................... � <br /> ............................................................................................ \ <br /> PHONE PHONE <br /> ........................................................................................... . . . ..L..DR....I.... .LLER.. ...................................................................... V <br /> PLUMBER WEL <br /> i <br /> ........................................................................................... .A...D...DRESS..................................................................................... m C) :�- <br /> ADDRESS <br /> ............... . . .................................................................... ............................................................................................ = <br /> PHONE PHONE O <br /> DESCRIPTION 9 0 <br /> 4. Sanitary Facilities: o <br /> 1. Work: 2. New Building Details No. Bathrooms Aj ' A ' <br /> .......... <br /> New Building ..... ,. Type of Construction: No. Bedrooms .......... 4. <br /> Addition .......... ....... <br /> Ttp�r,(.�.1.,�,,.... Septic Tank Size Gals. .......... <br /> Sanitary .......... Size ......L(a. ft. X ....3J[--)... ft. .......... <br /> Filling/Grading .......... Height............. Stories ....1......... 4a. Absorption Field Site: <br /> Moving .......... Area ........7qq6... vx ...... Soil Type ........................lV.r..R....• i <br /> o <br /> i <br /> Mobile Home .......... Slope .......................................... .. <br /> Priv Pend, Rate ................................... <br /> v .......... 3. Use (describe exactly, 1 -family <br /> Well Dry Well..... home,garage, motel, etc.) .......... <br /> Subdivision „ ,,,,,,,. �� �: Seepage Trench .......... I <br /> ............ ............. <br /> Camping UnitPriv <br /> ,,,,...... y .......... -� <br /> Seepage Bed .......... 1 <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road <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. <br /> o' <br /> __________________________________ ____ _________ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq. ft. <br /> ............................................................................... 6 <br /> N s” <br /> 0 <br /> Ju <br /> 0 <br /> s <br /> Z Z <br /> 0 <br /> a <br /> n r M m Z <br /> n V Q n < m F <br /> G C <br /> Z O O O <br /> O n <br /> fA <br /> fl ti f1.:.../ — n m <br /> �(.1.....,..... ......................... z o p <br /> . <br /> Signature ofr or Agent Date - = <br /> 1 x r M <br /> Remarks ......................................................................................................................................................................... .� m <br /> v <br /> ....................................................—................................................................................................................................. 0) <br /> L1 <br /> ............................................................................................................ . ....................... .. n <br /> ........ n N N ! 'M <br /> Inspection Date .........4............................. . .. . . - . .` `k. . . .... ... u, v, o <br /> Zoning Administr 7 L $ $ $ $ $ $ <br /> NOTE: A preliminary site inspection must be made and s e approve) 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 lie 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 Adm Inlstratoi. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />