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Burnett County Office of Zoning Administrator -+ 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 o. <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use c �p <br /> Ordinance, Sanitation Code, nd with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. a U\ <br /> 0�! _ <br /> ..................................................... .......................... ......................................................................................... cc O <br /> OWNER ( asease�print) CONTRACTOR or SURVEYOR or AGENT CD <br /> CL <br /> ................. ....................................................................................... <br /> ADDRESS ADDRESS ..... <br /> w <br /> ....1............................. <br /> Jo <br /> 1 ADD RE ADDRESS <br /> ................... PH..O...N.................................................................................... <br /> PHONE E <br /> .E....L... <br /> D..RIL.... ........................................................................... : <br /> PLUMBER WLLER � <br /> 0 a <br /> ADDRESS ADDRESS — <br /> o <br /> < <br /> ............ 0 <br /> PHONE PHONE <br /> DESCRIPTION o - r <br /> o <br /> 4. Sanitary Facilities: o - <br /> 1. Work: No. Bathrooms 7 <br /> 2. New Building Details ........ . <br /> o <br /> New Building x Type of Construction: No. Bedrooms .......... c :� <br /> Addition .......... ........... Septic Tank Size Gals. <br /> 11 <br /> Sanitary .......... Size ... ...... .. ft. x ..�`.... . ft. <br /> Filling 4a. Absorption Field Site: <br /> .......... Height. ... .... Stories ............... p <br /> Moving Area Soil Type .................................... c <br /> ......................................... . <br /> Grading Slope .......................................... <br /> o <br /> Mobile Home 3. Use (describe exactly, 1 family Perc. Rate ................................... <br /> Privy .......... home,garage, motel,etc.) Dry Well ....•..... 1 <br /> Well Seepage Trench .......... -j— <br /> .................................................... <br /> Subdivision Privy <br /> Seepage Bed ... W <br /> -------------------------------------------------------------- + <br /> Location of proposed structures and existing structures,well,sewage systems,roads,etc.,should be sketched in Fig. A. Include road <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- a <br /> section, show the intersecting highways and the set acks required along them and at the intersection. CLEARLY LABEL EXISTING i <br /> STRUCTURES AND PROPOSED STRUCTURES ND ADDITIONS. <br /> -------------------------- —------------------------------------------ ll <br /> 5. Lot Size: G Fig. A. 6. Location: <br /> � <br /> ft. x W........... f ............. ............. sq. ft. ................... ........................................................... <br /> CD <br /> C <br /> o <br /> o <br /> 0 <br /> r o <br /> I CD <br /> � z <br /> CD <br /> CD <br /> _ <br /> v <br /> 1 <br /> �� _ <br /> Z aaac — a <br /> m <br /> oyH : +� <br /> 0 <br /> f� h,07 1, <br /> m <br /> signature of Owner or Agent Date <br /> X <br /> emarks .................... ............ ......................... <br /> CD <br /> CD <br /> ......................................................... <br /> ........................................................................ . . ....... ........................................... 4 _.............................. o „ <br /> ispection Date ....................................... Q'. .. ...........�........... `............... 0 0 cNi, m <br /> Zoning Admi Istrator r ✓ o 0 0 6 0 o y <br /> DTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> fore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> is application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> 3 until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> th 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 />