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3urnett County Office of ZoningAdministrator <br /> \ 'I Istrator m 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT <br /> -O THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < H ° <br /> hown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use c ; ) <br /> /))rr�diiinnaance, Sanitation Code,and with all other applicable County Ordinances and the l(awss andrereg/u/)lations of the State of Wisconsin. � a <br /> .. .... .................................... .;`� ..................... ............................ <br /> )WNER (please print) CONTRACTOR or SURVEYOR or AGENT cCo CD <br /> O <br /> a <br /> ADDRESS ADDRESS <br /> ADDRESS ADDRESS <br /> HONE PHONE <br /> LUMBER WELL DRILLER ; <br /> 0 <br /> ,DDRESS ADDRESS <br /> c : <br /> h O <br /> PHONE <br /> ................................................................................. 0' .p <br /> HONE <br /> DESCRIPTION o '+ 0 <br /> 4. Sanitary Facilities: o ° <br /> Work: No. Bathrooms I <br /> 2. New Building Details <br /> New Building No. Bedrooms ° ' <br /> ......... Type of Construction: 0 <br /> Addition <br /> ......... .................................................... <br /> Septic Tank Size Gals. <br /> Sanitary .......... Size .............. ft.x ft. •'•'•"'•' <br /> Filling Hei ht Stories 4a. Absorption Field Site: <br /> g ............... <br /> Moving Type Soil T e .................................... <br /> .......... Area ........................................... r <br /> Grading .......... Slope .......................................... a ° <br /> Mobile Home 3. Use (describe exactly, 1 family Perc. Rate ................................... <br /> Privy ........ home,garage, motel,etc.) Dry Well <br /> Well Seepage Trench <br /> Subdivision •&"" Privy .......... <br /> .................................................... <br /> Seepage Bed <br /> -------------------------------------------------- ------------ <br /> ocation of proposed structures and existing structures,well,sewage systems,roads,etc.,should be sketched in Fig. A. Include roadI <br /> aback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- a <br /> .ction, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING �yt, <br /> TRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o• <br /> ------------------------------------------- --------------------- 0 <br /> O <br /> . Lot Size: Fig. A. 6. Location: <br /> I <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... C <br /> s-7 0CD <br /> U iLo <br /> 0 <br /> o <br /> Z <br /> 0 <br /> m <br /> U3 <br /> U3 <br /> co <br /> �o r - CnmZ <br /> CDc c� �. C co <br /> N N m <br /> OZ <br /> Ln <br /> Q G V p <br /> '.�/` o ........... ^� o C <br /> ....................................................................... ...................... ... . <br /> inature of Owner or Agent Date <br /> X <br /> marks „ . . . p <br /> m <br /> CD <br /> .................................................................................................................................................................................... 9 <br /> .................................................................................................P ,O .. C: 60 TLrnGOL....:... ... o: � o � Um <br /> pection Date o 0 0 0 <br /> ZoningAdmi Istrator `�J 0000000 <br /> TE: A preliminary site inspection must be made and site approval 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 /> application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> UnW a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> 1 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 />