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3u,'hett County Office of Zoning Administrator 0) CD 0 0 <br /> 1 <br /> ,. APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT a) <br /> 1 o <br /> f0 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 <br /> Drdinance, Sanitation Code, and with all other applicable County Ordinances <br /> ` 1 and the laws and regulations of the State of Wisconsin. 3 o <br /> * a <br /> .... .. ............................................................... ..... C CDDWfbd'ER (plea print) CO TRA OR or SURVEYOR or AGENT CDfD <br /> n i — <br /> /. ... ... ... .0........................................... 'a : <br /> CD <br /> 4DDRESS ADDRESS <br /> , .....,.. r.......... ..y�7. ................................ <br /> 4DDRESS ADDRESS <br /> ....................... <br /> SHONE PHONE <br /> .......................................................................................... ............................................................................................ <br /> 'LUMBER WELL DRILLER <br /> ............................................................ ......D...RESS.................................................................................. <br /> 4DDRESS AD o <br /> r* < <br /> . ................................................................................... ............................................................................................ O rr <br /> 'HONE PHONE z y r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Buildin Details •••'••"•• o <br /> 9 <br /> New Building .......... Type of Construction: No. Bedrooms _0 <br /> Addition .......... .................................................... Septic Tank Size Gals. <br /> Sanitary Size .............. ft. x .............. ft. .......... <br /> Filling .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area Soil Type ....................................e o <br /> Slop .......................................... <br /> Grading .......... D <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 /> .................................................... Seepage Bed <br /> ----- ---- ------------ --- ---------- Cn <br /> Location of proposed structures and existing structures,well, sewage systems, roads,etc.,should be sketched in Fig. A. Include road 6 <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- O <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING < <br /> H' <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> ------------ ------------------------------------------------------ O <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... <br /> 0`D <br /> N O <br /> O 7 <br /> p ,1 <br /> N <br /> t -n <br /> z <br /> o <br /> CD <br /> I � <br /> Cn r cn co z <br /> o C7 �. m C CD <br /> T. D_ C_< <br /> m <br /> <Lo M <br /> 0 0• m m � <br /> ...................................... o <br /> Signature of Owner or Agent Date — <br /> X <br /> Remarks ................................................................................................................ ........................................................ m M <br /> CD .0 <br /> Co <br /> ........................................................................................................ ...... I to <br /> o <br /> o <br /> T1 <br /> Inspection Date ....................................... ......:44. .. ....: ......................... kt o 0 0 0 0 o M <br /> Zoning Admi irtistrator � o 0 0 0 0 0 0 <br /> VOTE: 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 /> :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 /> ivith 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 />