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Burnett County Office of Zoning Administrator a -- 0
<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 < N7
<br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m �
<br /> Ordinance, Sanitation Code, and with all other applicabblle County Ordinances and the laws and regulations of the State of Wisconsin. 3 a
<br /> .:...... D F. .K 1. C�nr....... ..R.�11.4. TN.. ............ '�
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<br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT a
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<br /> ADDRESS ADDRESS
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<br /> ADDRESS ADDRESS ?.
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<br /> PHONE PHONE
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<br /> PLUMBER WELL DRILLER
<br /> ADDRESS............................................................................ RS
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<br /> PHONE PHON...... E
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<br /> DESCRIPTION 4. Sanitary
<br /> Facilities: ° o
<br /> 1. Work: No. Bathrooms ..........
<br /> 2. New Buildin Details o E
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<br /> New Building „ .. Type of Construction: No. Bedrooms ..........
<br /> Addition .......... .................................................... Septic Tank Size Gals. .......... i
<br /> Sanitary ,,,,,,,,,, Size ft. x ft. ”"""" '
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<br /> Filling/Grading Height............. Stories ............... 4a. Absorption Field Site: p
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<br /> Moving ..., Area o '
<br /> ........................... ............... Soil Type .................................... r
<br /> Mobile Home .......... Slope .................................I........
<br /> Privy .......... y Perc. Rate ................................... i
<br /> .......... 3. Use (describe exact) i -family r�
<br /> Wel .......... home,garage, motel, etc.) Dry Well .......... •v
<br /> Subdivision .......... Seepage Trench ..........
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<br /> Camping UnitPrivy ..........
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<br /> Seepage Bed .......... C) i
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<br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig. A. Include road Cu Q
<br /> setback, side and back yard dimension and location and setback from all bodies of water. If property * 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 i <
<br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o a
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<br /> 5. Lot Size: Fig. A. 6. Locatio : let 05/117
<br /> ft. r?5.'4 .:C?... ft. — ............................... sq.ft. ..447... 8lt..40]`..��..d/-3b'-L.7,....�L' !, .
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<br /> ignature Owner or Agent Date
<br /> Remarks ....rea to be graded is less than ten thousand square feet. x m
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<br /> Tod soil to be placed back in excavated area, seeded and/or mulchedv
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<br /> immediately after excavated. Area to be graded is to be staked
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<br /> 6 � o f 1a iv 9 m R N m
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<br /> Inspection Date ....................................... .. .... . .. :�. ./........ . ,��,,,,�„ ,I... ................... y: U o u, o v, m
<br /> Zoning Administrator /C j $ $ o $ 8 8 H
<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.
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