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Burnett County Office of Zoning Administratord o Z <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 9 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as '� 0 <br /> m <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use c <br /> Ordinance, Sanitation Code, and with all other applicable County ordinances and the laws and regulations of the State of Wisconsin, o. <br /> t. <br /> ......�>14..yer i �e. 3 <br /> ............T .. . ........................................................................ <br /> O�R (please print) CONTRACTOR or SURVEYOR or AGENT <br /> R.. .....l ........................................................... . .......................................................................................... a <br /> ADDRESS ADDRESS d <br /> I 1 t <br /> ADDRR <br /> .... ESD. 'ueS zsl.... <br /> r......Ails <br /> ADDRESS <br /> ........................................................................................... . ... ........... .� <br /> PHONE . ........................................................................... <br /> PHONE <br /> ........................................................................................... 4 1� <br /> PLUMBER . . ..................................................................................... "� <br /> WELL DRILLER Q <br /> :C <br /> ........................................................... A <br /> ................................ . .....DR.......ESS.............................................................................. <br /> � � <br /> ADDRESS D <br /> ........................................................................................... 0 <br /> < <br /> PHONE <br /> N r <br /> DESCRIPTION o :) <br /> 4. Sanitary Facilities: ° <br /> o ;\ <br /> 1. Work: No. Bathrooms ` •� w <br /> 2. New Building Details ..... . <br /> New Building No. Bedrooms ° <br /> Type of Construction: .......... a <br /> Addition •••••.....•.I........ Septic Tank Size Gals. .......... i <br /> Sanitary .......... Size ft. x ft. .� <br /> Pilling/Grading ......., . Height............. Stories ............... 4a. Absorption Field Site: i <br /> Moving ......I... Area Soil Type .................................... <br /> ........................................... <br /> Mobile Home . .... Slope .......................................... <br /> Privy . ..... 3. Use (describe exactly, 1 -family Perc. Rate ................................... 7j iJ <br /> Well home, rage, motel, etc.) Dry Well <br /> Subdivision ...•..... youSeepage Trench .......... .L�2 <br /> Camping Unit Privy <br /> __________ Seepage Bed .......... <br /> Location of proposed structures and eFisnng structures well, sewage systems, roads etc., should be sketched in Fig. A. Include road I Tr <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter j af— <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o-- <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Lootion: n —n�� <br /> ft. x .............. ft. — ............................... sq.ft. ..c ...ref.r.. !¢...:.cf.E'.�':.�P.�.�...S..+r!!N:��yW <br /> r � <br /> N o' <br /> €N <br /> 0 <br /> U s <br /> t � <br /> �1 0 Z <br /> ° <br /> _r)7art <br /> 11f f Ctp�I/wi 31 (n w Lw IO Z <br /> Qo <O. C <br /> "O IT G w .� <br /> p . <br /> 0 0 0 : n <br /> ' C o p K Ake w o ' . <br /> Signature of Owner or Agent Date <br /> Remarks ....... . . m <br /> ........................................................................................................................ <br /> X <br /> .. ... ... ...... ...... c!. . ......�L1`....... .....a ....5�,/.Ts7-....... '_ o <br /> ......�Jo7 ....../`".... e.... ..'.. .. .. . ...... <br /> . . <br /> Inspection Date ....................................... / , ,d nistrator <br /> �— �: o g 0 0 m <br /> c : <br /> o rii <br /> Zen ing Ag g o g to <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 Adm inlstratot. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />