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Burnett County Office of Zoning Administri for fP 17
<br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3
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<br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and � q M ;V�
<br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the $ c '--fl
<br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 '
<br /> regulations of the State of
<br /> Wisconsin. c G Q
<br /> M.a!.... .............6...�.L'...d.1.1 „ E/mt..Yr ......... ..................................................................................... ...... 3
<br /> OWNER (pies”print) CONTRACTOR or SURVEYOR or AGENT $
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<br /> ADDRESS ADDRESS tr�
<br /> . . . ................................................................................ . . . . .ESS.......................................................................
<br /> ADDRESS ADD.....R
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<br /> .7 .......................................................... PHONE :n 1
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<br /> PL WELL DRILLER
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<br /> ADp�p�J�//S�Sj� � ADDRESS i » 0 :CX'. . . ................ ...................................................... ..................................................................................... ...... O
<br /> PHONE PHONE ZN r 40
<br /> DESCRIPTION 4. Sanitary Facilities: ° o C
<br /> 1. Work: 2. New Building Details No. Bathrooms ... ...... c a6
<br /> New Building Type of Construction: No. Bedrooms ... ...... R
<br /> Addition Septic Tank Size Gals. ......
<br /> Sanitary ... Size .............. ft. x .............. ft. �• ) l is
<br /> Filling/Grading ,,,,,,,,,, Height............. Stories ............... 4a. Absorption Field Site: :l
<br /> Moving .......... Area Soil Type ............................ ....... `• r i
<br /> ...................................I....... r
<br /> Mobile Home .......... Slope .................................. ....... ^
<br /> Privy .......... 3. Use (describe exactly,'1 -family Perc. Rate ........................... .......
<br /> Well .......... home,garage,motel, etc.) Dry Well .. ....... T
<br /> Subdivision .......... Seep
<br /> age Trench o
<br /> Camping Unit .................................................... Privy
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<br /> ---------------------------------- Seepage Bed L X�
<br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fi . A. - g
<br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is local d at
<br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersect on.
<br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. ` ii
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<br /> 5. Lot Size: Fig. A. 6. Location: �
<br /> ................ ft. x .............. ft. — ............................... sq.ft. ....................................................................... .......
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<br /> Signaturr Agent Date
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<br /> RemarksL?....:.....!r..................................................................................................................................... .... p
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<br /> Inspection Date "! .. ..,,,,,,,, .. cn�, o' o N m
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<br /> Zoning Ad inistrator 8 8 8 $ 8 8 N
<br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary fac ilities before construction
<br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this appli ation 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 beer issued. A permit may be
<br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or pecifications shall not be
<br /> made without approval of the Zoning Administrator.
<br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APF ROVED.
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