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• �'7C fl7%�, <br /> Burnett County Office of Zoning Administri itor F c <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT 3. W <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 0 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements ol the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and <br /> regula 'ons of.the�tate of Wisconsin. 3• <br /> � /./•.Y1.nC../..�� 5.......................................... . . . ................................................................. ...... <br /> OINE plane print) CONTRACTOR or SURVEYOR or AGENT ; <br /> f. /.... X..s .......................... ......................................................................... ....... a �. <br /> ADDRESS ADDRESS me <br /> ......6......s..1.8....B.......b....0.....o..y .I.t./..I.. .....�....../..�...../...o.... <br /> .... .. ....... ................. ................................................................. ....... <br /> ADDRESS ADDRESS <br /> ......... ....................... .................................................................................... .......-... . <br /> �-C <br /> J <br /> PHONE PHONE <br /> k4q4*.....�-�..C.........o....??............................. <br /> PLUMBER WELL DRILLER <br /> ADDRESS ADDRESS 00 <br /> .-.. ....................................................... .................................................................................... . .... <br /> O <br /> PHONE PHONE Z <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details •• ••• ••• � c �1 <br /> No. Bedrooms <br /> New Building .......... Type of Construction: • h <br /> Addition Septic Tank Size Gals. . ....(./. 1 <br /> .... ..... .............qq,{ <br /> Sanitary .tom. Size .c7(..1�... ft. x .........�... ft. <br /> Fillip (Gradin 4a. Absorption Field Site: <br /> 9 9 .......... Height............. $t0lle5 ............... � :^ <br /> Moving .......... Area ........................................... Soil Type ............................ ....... Qn r <br /> o <br /> Mobile Home .......... Slope ....................3 <br /> ... ..... ....... <br /> Privy ..,,,,,.,, 3. Use (describe exactly,') -family Perc. Rate ........................... ....... o <br /> Well home,garage,motel, tc.) Dry Well .. ....... m i T <br /> ..........Subdi /_ / Z <br /> Camping <br /> U _..••...•. ! yQ ZA'Y�Q�J Seepage Trench .. ....... 0 <br /> --Camping Unit— ........ ......... . ..... ....... . Privy .. ..... . <br /> .......... i <br /> ..I.................... Seepage Bed <br /> --------------------------------------------------------- -- <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fi A. �QJ = <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is local d at 6' i L <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersec ion. .S�j <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. :O o <br /> --------------------------------------------------------- — <br /> 5. Lot Size: Fig. A. 6. Location: .� <br /> ................ ft. x .............. ft. — ............................... sq. ft. ....................................................................... ....... <br /> o � <br /> N .� ° <br /> 00 <br /> m <br /> (\ Z <br /> �d O <br /> p <br /> a <br /> ® m <br /> S <br /> m :c mtm r > w m -0 <br /> m �a� a 0 n a g <br /> a < d C 0 > j 3 <br /> N m (p <br /> O fn0 D <br /> o a Im <br /> o c' 0 m <br /> ^ : rn <br /> n . m <br /> Signature of�Owner or <br /> ar , Agen�t Date <br /> Remarks : ......................................................................................................... .... 'o <br /> m a <br /> .........................................C/��C� .... --kms.. <br /> o : o <br /> 0 0 <br /> Inspection Date .. .................."-'.. ... ....... .. .... . .:...... .. .�n�. . a N N o o <br /> .7 m <br /> Zoning Adminis t for 0 8 8 0 o g fmA <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary fa ilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this appli 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 beer issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or pecifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APF ROVED. <br />