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Burnett County Office of Zoning Administrator o z <br /> o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as H ° <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land UseCDc V Ordinance, Sanitation Code, and with all other applicable Count Ordinances and the laws and regulations�.O .. <br /> e State of Wisconsin. I a :C <br /> z �C <br /> , �.. .... ... .'�. ................... ......... .. . y <br /> N : < <br /> OWNER (WI ase print) CONTRACTOR or SURVEYOR or AGENT a ID <br /> ro <br /> i..F 1.......................... o <br /> ADDRESS "" ' <br /> ADDRESS <br /> - ....r....... ....... ............. ... ......... .��.ADDRESS ......... ..... ADDRESS \ <br /> ........................................................ .................................. ............................................................................................ <br /> PHONE :\ <br /> p �— PHONE <br /> . 0. ...............7...... ...................................... <br /> PLUMBER WELL DRILLER <br /> ADDRESS . .. ............................................................................ � <br /> ADDRESS.. ...... C <br /> CD0 <br /> .................................................................................. — < <br /> PHONEPHON.E........................................ ....................................... o <br /> DESCRIPTION 4. SanitaryFacilities: ° o <br /> 1. Work: 2. New Building Details No. Bathrooms ......... <br /> o <br /> New Building Type of Construction: No. Bedrooms <br /> Addition ••,•„•... „••,•„••• . Septic Tank Size Gals. <br /> / �y a ; <br /> Sanitary .......... Size .. .... ft. x .p . ? .. ft. <br /> Filling Height............. Stories .... .......... 4a. Absorption Field Site: <br /> Moving Area Soil Type .................................... y i <br /> .......................................... j r <br /> Grading ......... Slope ....................................... .. o <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Privy Dry Well p <br /> .......... home,garage, motel, etc.) 1W <br /> Well .......... Seepage Trench .......... <br /> y <br /> Subdivision Privy 1 <br /> .... .......................... p g <br /> See a e Bed .......... <br /> ---------------------------------------------------------------------- <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- U� a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING t < <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. y <br /> o <br /> ---------------------------------------------------------------------- <br /> 5. Lp e: � Fig. A. 6. Location: <br /> ft. x .............. ft. — ............................... sq. ft. ............................................................................... <br /> fN <br /> (D <br /> C) <br /> N O <br /> O <br /> N <br /> r� rf <br /> / O <br /> CD <br /> o <br /> /J�r <br /> to� <br /> m <br /> :V <br /> L ar � � d OOZ <br /> — — <br /> L. <br /> -O cn < �• <br /> ff m <br /> o <br /> z o o <br /> o - � <br /> cn <n <br /> 1 0 <br /> f �' ! <br /> 70 <br /> / !A <br /> G1....... .Y'..................... ..................................... o ! m <br /> _i nature of Owner or Agent Date �+ p <br /> X ?t-4: M <br /> Remarks ......................................................................................................................................................................... -n M <br /> CD <br /> m <br /> ....................................................................................................................................................................................... :o <br /> ........................................................................................................ . <br /> : ! m <br /> nspection Date ....................................... Q!rtZ.lag. ...�............ ....:.......... <br /> 000 <br /> Zoning Admi istrator /c� 0000000 <br /> OTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> efore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> its application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> rg until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> ith 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 />