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Burnett County Office of Zoning Administrator F 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 '� 0 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the j <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> re ulat n of the State isconsin. <br /> ..V�►.I i m.. u�:�.�I .ba . .... Cfan:�....... . C <br /> a <br /> OWNER (please print) CO ACT or SURVEYOR or AGENT <br /> ADDRESS .......................................... .ADDRESS 'n <br /> ( <br /> oA.St... .. . .+.�.1n1...� .7.5................. .....: ..ren..,.. ... .$.7.. ............................... <br /> ADDRESS ADDRESS • <br /> .. ........................................................................................ .P. .HONE. .................................................................................... . <br /> PHONE <br /> .......... <br /> ........................................................................................... .WE.. ... ..L...D..RIL.. L................................................................... <br /> PLUMBER LER 7G -� <br /> 0 <br /> ........................................................................................... . ...R...ES................................................................................ _. <br /> 0 <br /> ADDRESS ADD..... S � • <br /> .................................................. O <br /> 0 .i <br /> � <br /> . ....................................................................................... . ................................... <br /> PHONE PHONE...... Z <br /> DESCRIPTION 4. Sanitary Facilities: ° o » . <br /> """""Bathrooms I <br /> 1. Work: 2. New Building Details No. Bat <br /> New Building .......... Type of Construction: No. Bedrooms .......... <br /> Addition ......................I............................. Septic Tank Size Gals. .......... <br /> .......... <br /> Sanitary Size .............. ft. x .............. ft. .......... <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... Soil Type .................................... o Mobile Home Slope .......................................... <br /> .......... <br /> Privy .......... 3. Use (describe exactly,'I -family Perc. Rate ................................... � i <br /> Well home,garage, motel, etc.) Dry Well .......... m <br /> Subdivision Seepage Trench .......... o <br /> . . ............... ..................................... <br /> Privy Camping Unit .......... .................................................... i <br /> p g <br /> See a e Bed .......... <br /> --------------------------------------------- __---- :J1 i to <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. :— Ji <br /> j, <br /> road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at ,`'�:_� i 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. ,'�:'�� i <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... <br /> cs� <br /> f/,I O i O <br /> 2 <br /> ► I Pa �s a3q-a � � ,�� <br /> s o <br /> J ' 0 Z <br /> 0 <br /> 9 <br /> d <br /> 00CCm <br /> m Nn•< — am nn y <br /> ao< ; dcy > > 3 <br /> P mn <br /> a ; y <br /> 2H In <br /> ° : O <br /> c <br /> z <br /> x A . m <br /> §ig- ...ature......of....O...w...n..er... .or.....A..gen....t. ............................... .................D. ..ate.. ................ a O <br /> Sign. o <br /> Remarks m a <br /> b <br /> ........................................................................................................... ... .................. .. ... . ...... ........... .................... <br /> Inspection Date ....................................... ...... . . . . .. ... ,�ry�r N N 0, o 'o m <br /> Zonin Admi i rator-�' r o $ $ g g o N <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 />