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Fj •�{r�[ C_t <br /> Burnett County Office of Zoning Administrator c -0o 0 <br /> 2 i <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use mI CD <br /> e <br /> Jrdi ance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 n. <br /> N � G <br /> OWNER (please print) CO�CTOR or SURVEYOR or AGENT a <br /> 4V1.................................................. �S <br /> 4DDRESS ADDRESS <br /> .... ............................................................................................ <br /> 4DDRESS ADDRESS <br /> .......................................................................................... <br /> 'HONE PHONE <br /> .......................................................................................... . ..L...L..D..RI......LL........................................................ <br /> ................. <br /> 'LUMBER WE... ER 1, <br /> .......................................................................................... ........................................................................................... <br /> v <br /> 4DDRESS ADDRESS m r7 <br /> 0 o <br /> Or+............. : <br /> 'HONE PHONE z H � <br /> DESCRIPTION 4. SanitaryFacilities: ° o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details ......•••• ` o <br /> New Building .......... Type of Construction: <br /> No. Bedrooms .......... ' <br /> CD <br /> Addition Septic Tank Size Gals. .......... <br /> .......... . . . <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... <br /> Filling ,,.,,,,,,, Height............. Stories ............... <br /> 4a. Absorption Field Site: <br /> Moving .......... Area Soil Type .................................... r <br /> O <br /> GradingSlope .......................................... �+ <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... E <br /> Privy ......... home,garage,motel,etc.) Dry Well .......... <br /> Well Seepage Trench .......... <br /> .......... .................................................... Privy <br /> Subdivision .... ......•••• ' <br /> .................................................... <br /> Seepage Bed .......... <br /> ---------------------------------------------------------------------- N <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road C <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- n <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING y <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. p' <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... <br /> s J� 01 <br /> I o o. <br /> N <br /> z <br /> O <br /> (gyp <br /> C NCD 0)0 7 < 0 C CD <br /> * <br /> v 'O Ul < � � 7 C <br /> oO <br /> .A'U C p <br /> o <br /> Signature of Owner or Agent Date <br /> X <br /> Remarks ` ` ' <br /> CD <br /> CD <br /> 1 v <br /> ........................................................................................................................................................................................ II <br /> ........................................................................................................................................................................................ V1; <br /> c m <br /> Inspection Date ....................................... o 0 0 0 o cNn m <br /> cn <br /> pG. 4................:..g........ \. <br /> Zonis Ad Inistrato 0 0 0 0 0 o cmn <br /> DOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> iefore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> his application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> ng until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> vith is found to exist. Changes in plans or specifications shall not he made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />