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Burnett County Office of Zoning Administrator3 ? o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < N µ W <br /> shown herein. The undersigned agrees that all work shall be done In accordance with the requirements of the Burnett County Land Use m e �:0 <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. _ a <br /> 3. <br /> 0 <br /> C <br /> OWNER (please print) CONTR TOR or SURVEYOR or AGENT <br /> f <br /> _ <br /> ...3�y..................................................................... ......................................... a <br /> AD RESS ADp�ESS <br /> ! .,../N./..... �..5 <br /> ......................................... S. /X70.................................. <br /> ADDRESS ADDRESS <br /> ........................................................................................... ............................................................................................ <br /> i CV <br /> PHONE <br /> .......... <br /> ........................................................................................... .WEL.. ... ...L...DRILL.........ER............................................................. <br /> PLUMBER <br /> 0 <br /> ........................................................................................... ......................................................................I..................... _. <br /> ADDRESS ADDRESS n o <br /> < <br /> ........................................................................................... ................................................... ....................................... O D <br /> .e <br /> PHONE PHONE Z r <br /> DESCRIPTION 4. SanitaryFacilities: g o <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details •••• 3 0 <br /> 9 <br /> New Building •,•„•,•„ Type of Construction: No. Bedrooms .......... w<p <br /> Addition ....,.•,•• ....,. Septic Tank Size Gals. .......... i <br /> ....... .................... ................. <br /> Sanitary .......... Size .............. ft. x ft. .......... :A <br /> Filling/Grading ...I...... Height....... Stories ............... 4a. Absorption Field Site: <br /> Moving ..... Area .......... Soil Type .......................... <br /> .......... .......... ° s. r E <br /> v <br /> o <br /> Mobile Home <br /> Slope .......................................... U <br /> .......... { <br /> Privy .......... 3. Use (describe exactly, 1 -family Fare. Rate ................................... � <br /> Well ,......... home,garage, motel, etc.) Dry Well .......... '. <br /> Subdivision .........9e Trench .......... C <br /> . ..✓..... ...........................4........................ <br /> Camping Unit .......... Privy .......... <br /> .................................................... Seepage Bed .......... 0 <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. It property is located at a highway inter- o- <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. o <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: i <br /> ................ ft. x .............. ft. — ............................... sq.ft. <br /> -�� N O <br /> O = <br /> I z <br /> 0 <br /> \� o <br /> d <br /> t iV <br /> I <br /> m Z <br /> C d d C N <br /> '\ n is n f <br /> a rn < C M <br /> oN zmgm <br /> 0 00 n . 9 <br /> � 3 <br /> o �p <br /> . 3.- /9.:x./ .moo c <br /> Signature of Owner or Agent Date — <br /> X <br /> Remarks ......................................................................................................................................................................... f m <br /> m <br /> F» <br /> ........................................................................................................................................................................................ W II <br /> NA <br /> ....................................................................................................... ............. / <br /> : IO: T <br /> o:o1 Nru°1io ,r�iroum <br /> InspectionDate ....................................... /n�0. .. .............. .............................. : c $ 8 8 8 8 8 m <br /> Zoning Admin Straton �J ° in <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 />