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Burnett County Office of Zoning Administrator �' 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 o, <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m c <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the law and 3 [� <br /> regulations of the Sate of Wisconsin. [ n <br /> �.. .n.. .........5 e�c.n.. ......................... ............................................4.n l.........���..��p.Fs <br /> OWNER (plea»print) CONTRACTOR or SURVEYOR or AGENT <br /> ..... ............................................................................................ a <br /> ADDRESS ADDRESS mi Ij - <br /> 1 .. ... s..... .. .............. ......... ............................................................................................ �7 <br /> ADDRESS ADDRESS <br /> ........................................................................................... ............................................................................................ <br /> t i3 <br /> PH PHONE <br /> .. ... .. -.. ...S............................................... ............................................................................................ u, <br /> PLUMBER WELL DRILLER ;C;C3 <br /> ............. <br /> ........................................................................................... . .. .. ................................................................. 0 <br /> ADDRESS AD.....DRES.. ..S is G) <br /> on o <br /> ............. <br /> . . . ................................................................................... .-H-O-........................................................................ <br /> PHONE PHONE <br /> P r <br /> DESCRIPTION 4. Sanitary Facilities: P o ° <br /> 1. Work: 2. New Building Details No. Bathrooms .......... i �c , <br /> New Building f(-.,, Type o Construction: No. Bedrooms ..` ( � <br /> Addition ,,,,,,,,,, ,,,,,, , r»t "4 Septic Tank Size Gals. ... <br /> .......... !! ��.yy. ........... <br /> Sanitary ...�(;.. Size .1p.... ft. x .A....�... ft. .......... W . <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> r <br /> Moving .......... Area Soil Type .................................... r <br /> o <br /> Mobile HomeSlope .......................................... 'U o <br /> Privy Perc. Rate ................................... <br /> d <br /> 3. Use (describe exact) - mil ; <br /> Dry Well <br /> Ay/ ,$ home,garage, motel, etc.) "'"""' <br /> r 0 <br /> „ <br /> --SaSeepage Trench ion -.... .. <br /> .................................................... <br /> .......... o <br /> Camping Unitt Privy <br /> ........ ............. --- Seepage Bed— <br /> ------------------------------------- --------- <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. moi. \ fig <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at 1 �. <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. : 0�. <br /> ---------------------------------------------------------------------- i <br /> 5. Lot Size: Fig. A. 6. Location: 'in................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... <br /> >�. 0 <br /> 0o <br /> T? 30' I ;eb t <br /> Z <br /> M .W -vmr Doo W -0 <br /> c`Di Co ' = 'O `- `- m <br /> a < m co J ° <br /> O V'. <br /> N p m C) 3 <br /> Z y^ro r D 1 <br /> Cn <br /> ,rte <br /> 0 <br /> J //////]] <br /> Irn <br /> Signature of Owner or Agent Date o <br /> Remarks ... f.(.. .,�..c.... ..'...................................................................................................................... <br /> ............................................................................................................. ..... ......... .... .. <br /> Z ........... ........... <br /> Inspection Date oning dminstrator <br /> N N8 <br /> O vN <br /> 8 g <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities before constructi n <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation fest 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 />