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Burnett CountyOffice of Zoning Administrator K,Y 0 o <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 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 c ;\ <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of,the State of Wisconsin. 3 g) <br /> n <br /> OW (pl e print)�°........... ........................................... <br /> OW (please LCA^f� ✓ C NTRACTOR or SURVEYOR or GENT [� a m <br /> . ... ..:. .. . <br /> .. . . . . .............................................................................. <br /> ADDRESS ............................................................................................ n <br /> ADDRESS <br /> ADDRESS ADDRESS <br /> ................................................... <br /> PHONE ........................................ . .......................................................................................... <br /> PHONE <br /> l <br /> ........................................... <br /> ......... <br /> ....................................... '� <br /> WELL DRILLER -� <br /> ........................................................................................... <br /> ADDRESS . .......................................................................................... <br /> ADDRESS G) <br /> n O <br /> ........................................................................................... M <br /> PHONE <br /> DESCRIPTION 4. Sanitary Facilities: ° o 0 <br /> 1. Work: 2. New Building Details No. Bathrooms .......... <br /> v A <br /> New BuildingNo. Bedrooms <br /> .......... Type of Construction: <br /> m :Yl <br /> Addison .......... .................................................... Septic Tank Size Gals. .......... <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... <br /> FillinglGrading ,,,.,,,,,• Height..........:.. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... Soil Type .................................... <br /> r <br /> Mobile Home Slope .......................................... O <br /> .......... <br /> .. <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ...........................I....... <br /> well ,••,,,,.,, home,garage, motel, etc.) Dry Well .......... i <br /> Subdivision .-� Seepage Trench <br /> Camping Unit -,,,,,.... Privy .......... <br /> .................................................... Seepage Bed <br /> ---------------------------------------------------------------------- <br /> Location of proposed structures and existing structures,well, sewage systems, roads etc., should be sketched in Fig A. Include road o. <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 .............. <br /> .fft. . ../........................... sq. ft. ............................................................................... <br /> Uj 011 <br /> 0 <br /> N o <br /> i <br /> C) <br /> — s <br /> �a z <br /> O <br /> �'I n O m <br /> MN r 9 � N W Z <br /> m c <br /> m n <br /> < M <br /> z - a <br /> M <br /> o � a ' � <br /> F a <br /> an <br /> o <br /> .............................. �/�/res <br /> Signature of Owner or Agent Date <br /> E <br /> X <br /> Remarks ......................................................................................................................................................................... r vm <br /> m <br /> ........................................................................................................................................................................................ <br /> ...................................................................................................... ..... ............................ . ........................................... :� . . . . . . <br /> Inspection Date ,'o m <br /> �.a:. ..... ........�� u................... $ m <br /> Inistrator <br /> Zoning <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 be made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />