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I <br /> 3urnett County Office of Zoning Administrator 0) CD 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. 3 <br /> -O THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as y 0. <br /> hown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m C <br /> )rdinance, Sanitation Code,and with all other applicable County Ord!' nces and the laws and regulations of the State of Wisconsin. 3 a v <br /> ... ..b..... ............ ... .f........... .. ............................. y <br /> )WNER (please print) CONTR TOR or SURVEYOR or AGENT <br /> ID <br /> ADDRESS AD ESS <br /> � �..........................�� ........................................... <br /> ................ <br /> >DDRESS ADDRESS ' <br /> 'HONE PHONE <br /> ....................................................................... : <br /> 'LUMBER WELL DRI LLER <br /> .......... <br /> .......................................................................................... ......DRES.... ..S.... .................................................................. 1. <br /> ADDRESS AD 0 C <br /> • <br /> c < <br /> .......................................................................................... . . ................................................................................ 7 ri , <br /> SHONE P..H..ONE.. .... Z H r <br /> DESCRIPTION 4. Sanitary Facilities: ° c ° <br /> 1. Work: 2..New Building No. Bathrooms """"" <br /> Details o <br /> New Building No. Bedrooms "o <br /> Type of Construction: """"" <br /> .......... . . . <br /> Addition .......... <br /> Septic Tank Size Gals. <br /> ................................................... <br /> Sanitary .......... Size .............. ft. x ft. " """' <br /> Filling .......... Height............. Stories ............... <br /> 4a. Absorption Field Site: <br /> SoilType .................................... r <br /> Moving .......... Area ........................................... o <br /> Grading .......... Slope .......................................... �+ <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... fi <br /> Privy home,garage, motel,etc.) Dry Well <br /> Well Seepage Trench .......... <br /> Subdivision <br /> .................................................... <br /> Privy .......... <br /> ...�... .................................................... <br /> Seepage a e Bed .......... l <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road a <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- <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. <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: ii '•� <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... <br /> I E <br /> 0 <br /> ,GII 0 <br /> o � <br /> •Y•v„Q . 9 �, . a o S <br /> CD <br /> o � <br /> 0CD <br /> �C <br /> CD <br /> �� rncoZ <br /> 0 Cr <.�:3 <br /> p rn' < co g M <br /> Z <br /> CD M <br /> .../O — /....... o C <br /> Signature of Qwner or Agent ^ Datg� // �` �� <br /> y,� <br /> Remarks f.��(i��i'��.....,��........�t��....... //'GtL 7 CD � <br /> iv rc, m0 <br /> CD <br /> cS(r I � <br /> .................. ....................... ...... ............................................................................................................. W u <br /> 4 <br /> ......................................................................................................... ... .................... . ................................................. :lob -n <br /> o <br /> Inspection Date +�•� 0 0 o m 00 <br /> o cn m <br /> Zoning Admini rator : Qp 0 0 0 0 0 0 Cn <br /> DOTE: 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 /> 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 be made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />