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111 ' J <br /> Burnett Co,znty Office of Zoning Administrator o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ; B <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 UseCD <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> _ Q <br /> N <br /> OWNER (pleas rint CONTRACTOR or SURVEYOR or AGENT m m <br /> a <br /> ................ ... . .................................................................... ............................................................................................ <br /> a <br /> ADDR ADDRESS <br /> ADDRESS ADDRESS :� <br /> ........................................................................................... ......................................................................................... <br /> 01 <br /> PHONEd5� ^ ^125Z PHONE <br /> '.././...................................................... .E........D. .... ..................................................................... <br /> PLUMBER WLL RIL.... LER.. <br /> .................................. AD...D...RES'E'S"S............................................................................. CD 0CD o <br /> ADDRESS <br /> ' <br /> ........... <br /> 0 <br /> P ..NE.......................................................................... <br /> PHONE HO.. <br /> DESCRIPTION 4. Sanitary Facilities: o o <br /> 1. Work: 2. New Building Details No. Bathrooms ......... <br /> T <br /> o <br /> New Building X.... Type of Construction: No. Bedrooms .......... -G <br /> CD <br /> Addition ...... Septic Tank Size Gals. .......... <br /> . .......... ...................... ..................... . . <br /> Sanitary .......... Size ft. x ft. ......•••• <br /> .......... Hei ht Stories p <br /> Filling g 4a. Absorption Field Site: <br /> Moving Type Soil T e .................................... r <br /> ... Area ........................................... <br /> Grading Sloe <br /> Mobile Home .......•.. 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Privy .......... home,garage,motel,etc.) Dry Well .......... �— <br /> Well Seepage Trench <br /> .................................. .......... <br /> Subdivision Privy <br /> .......... <br /> Seepage Bed <br /> ------------------------------------------------------------------ - -- �. <br /> Cn <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road 1F <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- { / Q <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. /�ys `; <br /> ---------------------------------------------------------------------- NJ o <br /> 5. Lot Size: /D Fig. A. 6. Location: ( '� <br /> ✓ <br /> ft. x ... — ............................... sq. ft. <br /> Cn <br /> N p <br /> See &a-e-Ad 5kak� <br /> n fp�('. Sa�„r� 5 Si"�r� �w� I►"' �- ��`.�3 S�� ��rM..�" � o <br /> --2 y <br /> o <br /> a <br /> in <br /> m <br /> :V <br /> M Nr - NcoZ <br /> CD c m :!. m c co <br /> Z 0 0 <br /> o <br /> .... .. ........................................................ .............. �................ m o <br /> gnature of Owner or Agent Date <br /> X <br /> m <br /> CD <br /> ..................................................................................................................................................................................... -- <br /> u <br /> .............................................................................................?site <br /> ............... ................ I <br /> . ... ... . .. <br /> qn <br /> spection Date ....................................... .. 0 cC'n <br /> 0000' 0 <br /> ZoningAdmini ra� o o o o 0 <br /> ITE: A preliminary site inspection must be madepproval granted on all structures involving sanitary facilities <br /> ore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> s application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> h 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 />