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Burnett County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 3c UJ <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described End <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of 1 he <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws End 3 <br /> regulations of the State of Wisconsi n. M g K1 <br /> ..... .... .`.!. ........................................... ... �.. ..........................'....1................... . <br /> OWR (please print) CONTRACTOR or SURVEYOR or AGENT ;� <br /> ....q.x..../.3.. ............................................................. ...................................................................................... .... a i <br /> ADD ESS ADDRESS -I <br /> ...... ...n : '�........... ...................................................................................... ..... <br /> ADDRESS ADDRESS <br /> I <br /> PHO/r/�7F j� PHONE <br /> r 4 �6..!.1...f.h. <br /> WELL DRILLER I <br /> PLUMBER '� <br /> K A <br /> O <br /> ........................................................................................... . . ...... ........................................................................ ..... <br /> ADDRESS ADD.. .. RES..S 0 C j <br /> ...... ..... O <br /> .................................. <br /> . ....................................................................... ^i <br /> PHONE P..H..ON....E Z „ r. <br /> DESCRIPTION 4. Sanitary Facilities: P g o <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details c <br /> New Building No. Bedrooms .... <br /> .... Type of Cc •••' $ <br /> Addition t— ^4 +vlt Septic Tank Size Gals. .... .a <br /> ....... .................................................... <br /> Sanitary Size .....A.U... ft. x ...,3..9.... ft. <br /> ..�... 4a. Absorption Field Site: y n <br /> Filling/Grading .......... Height............. Stories ............... <br /> Moving .......... Area Soil Type .............................. ..... i <br /> ........................... ......... .. - o <br /> Mobile Home Slope .................................... ..... <br /> Perc. Rate ............................. .... .. <br /> . m <br /> Privy .,,,,,,.,, 3. Use (describe exactly, -famil 0 <br /> Dry Well T <br /> well .......... home,garage, motel,etc. '••• ••'•' — <br /> subdHiaton Seepage Trench o i <br /> .......... .................................................... Privy ..... <br /> Camping Unit <br /> .......... .................................................... i <br /> Seepage Bed <br /> ____________________________________________________________________ _ <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig A. <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is locateat ' <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersects n. H <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> __________________________________ —_____-----------_------_-------_ _ + <br /> 5. Lot Size: Fig. A. 6. Location: <br /> jn <br /> ................ ft. x .............. ft. — ............................... sq. ft. ........................................................................ ...... <br /> C <br /> 0 <br /> o <br /> CN <br /> J <br /> 0 <br /> � o <br /> f <br /> j <br /> (, v <br /> Z <br /> o <br /> v <br /> e <br /> A <br /> I � <br /> X/ m .c v m v > rm ao& <br /> rri <br /> t D O Nf N ep rp <br /> D � � <br /> rno <br /> 9 0 <br /> ..........\... .... .................................................... ......1................... ........ A <br /> C <br /> Signature of nerZ2'.. <br /> or,Agent Date o <br /> Rema s� �..,�.G <br /> ....... . . . . . .. ............ ............ ................... ........ . <br /> » rn <br /> ..:................................................................................................................................. ... <br /> � <br /> .............................. . ................. <br /> Inspection Date <br /> /......................`......................................................... ..... . ........... . ... o : $ <br /> ....::................................. ....... ........................9.. .. o o . m <br /> Zonin dministrator 8 8 8 8 8 8 rn <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary fac lities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this applih 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 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 s Decifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APP OVED. <br />