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Burnett County Office of Zoning Administrator d 1 o V/Z <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> m O <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < N -� <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use ;F ?"ll <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 n i <br /> o..,.a.n.n..........13.0.R... ..e. . <br /> . N <br /> o <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT n <br /> .rss.....Y.. ... ....!]an.b.il!�..sJ..�.IV�..... ................ ' <br /> ADDRESS ADDRESS » <br /> ..............................4)... .c�..4}................ ............................................................................................ <br /> :C <br /> ADDRESS ADDRESS <br /> ..............�oJ.�o..-s3.�J.Q............................................ . . . ...................................................................................... <br /> PHONE PHONE 1 <br /> ................................................ <br /> .. ...... . ............................................................................... . . . ... . .. . ....................... "n <br /> PLUMBER WEL..L D..RI LLER !U� <br /> AODR <br /> .......... <br /> ESS............................................................................ RS <br /> .ADDES .................................................................. r�0o 0 <br /> PHONE PHONE Z o r' <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms .......... c:,E <br /> 2. New Building Details o <br /> New BuildingNo. Bedrooms .......... <br /> .......... Type of Construction: ro <br /> Addition ... ... .................................................... Septic Tank Size Gals. .......... <br /> Sanitary <br /> .......... Size .... ft. x ... ..C?..... ft. .......... <br /> Filling/Grading .......... Height............. Stories .... ......... 4a. Absorption Field Site: . <br /> Moving Area Soil Type .................................... r <br /> Mobile Home .......... Slope .......................................... » <br /> Privy .......... 3. Use (describe exactly, 1 -family Fare. Rate ................................... <br /> �. <br /> Well .......... home,garage, <br /> .. . . . ..... mote),,.etc.) <br /> Dry W <br /> ell <br /> Subdivision Seepage Trench <br /> ....... � ................................ <br /> Camping Unit Privy ".."."." <br /> .......... e ......... . .•..'".•.-". <br /> -� <br /> ii <br /> v <br /> Seepage Bed .......... . <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road r <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter <br /> a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING un9 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. p' <br /> ___ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... <br /> m <br /> n <br /> N O <br /> O � <br /> o €J <br /> io •-9 " o <br /> I n <br /> lid <br /> I <br /> Z <br /> Q. <br /> a <br /> � 5' Dam <br /> 0 0 <br /> ; <br /> v, 3 <br /> OJ�2 SOU dee '}� Fin �o o <br /> 0 <br /> . o <br /> Signature of Owner or Agent ✓ Date — <br /> X <br /> m <br /> Remarks ..........................................................................:.............................................................................................. m m p <br /> m <br /> .....................................................................................................(./`./. ............ ............................................................... 1� <br /> Inspection Date ....................................... �jt' d �. ........ E o u o o ren m <br /> ....... ...... g ......... ...... .. ..�........ E <br /> Zonin Adm nistrator $ 8 $ 8 8 8 y <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 he issued. Do riot 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 Adm inistrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />