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ON COMPUTER/SCANNED ( J
<br /> Burnett County Office of Zoning Administrator d �' 0 0
<br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT3
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<br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and IocFted as < ._. �
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<br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County La id Use m C
<br /> Ordinance, Sanitation Code, and
<br /> ,{with
<br /> ,all
<br /> t other applicable County Ordinances and the laws and regulations offtthe State of Wisconsin. 3 �a
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<br /> OWNER (please print) COPdT)9ACTOR or SURVEYOR or AGENT �
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<br /> ADDRESSi .... ..................... .
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<br /> ADDRESS
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<br /> PHONE . ................................................................................ ......... � �� I
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<br /> ........................................................................................... WEL. . L DRI. ...........LER.......................................................................... �,•
<br /> PLUMBER L 'V
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<br /> ADDRESS m G)
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<br /> ........................................................................................... ....PHONE..... ................................................................................... ^-
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<br /> DESCRIPTION r
<br /> 4. Sanitary Facilities: ° 0 0
<br /> 1. Work: 2. New Building Details No. Bathrooms
<br /> New BuildingNo. Bedrooms 0 .�
<br /> .......... Type of Construction: ....•• s
<br /> Addition .......... .................................................... Septic Tank Size Gals. ..........
<br /> Sanitary ,,,,,,,,,, Size ft. x ft. ......
<br /> .............. ..............
<br /> Filling/Grading ,,,,,,,.,, Height............. Stories ............... 4a. Absorption Field Site:
<br /> Moving ..... Soil Type ...................
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<br /> Mobile Home Slope .......................................... 0
<br /> Privy .. ....... 3. Use (describe exactly, 1 -family Perc. Rate ...................................
<br /> Well ,,, .,,, home,garage, motel, etc.) Dry Well ..........
<br /> Subdivision ,�.. Seepage Trench ..........
<br /> Camping Unit .........IPrivy .......... .
<br /> ....................................................
<br /> Seepage Bed
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<br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched In Fig- A- Induce road C
<br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highwa inter a/ l
<br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXI TING
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<br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o-
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<br /> 5. Lot Size: Fig. A. 6. Location:
<br /> ................ ft. x .............. ft. . ............................... sq. ft. .................................................................... .......... y,-
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<br /> Signature of Owner or Agent Date .'`0 C
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<br /> Remarks .................................................................................................................................................................. ...... m
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<br /> Inspection Date ............ .... .. ........ . ,;f�1�,!_. m
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<br /> -j Zoning Administrator; y� i� $ 0 0 0 0 $ Cn
<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, it 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 he made without approval of the Zoning Adm inlstratol.
<br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE ND APPROVED.
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