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Burnett County Office of Zoning Administrator o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. <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 Use CD c <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. I M <br /> !...!.. .U�.. ..........: ....................... ............................................................................................ <br /> F O <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT CD v m <br /> �D <br /> (r'.... .1.......... ....�� ............... ............................................................................................ <br /> AD ESS ADDRESS <br /> ADDRESS ADDRESS :j C <br /> ............ <br /> PHONE PHO � '�' <br /> f�o�.� ..c�s...... .... F�.F_R................... gyp/ <br /> PLUMBER (,� <br /> ......' 6.... .... <br /> ADDRESS ADDRES!S <br /> CD <br /> oO <br /> _. < <br /> 7Z ........................................................ o <br /> PHONE PHONE <br /> DESCRIPTION z �^ r- <br /> 4. Sanitary Facilities: o° ° <br /> 1. Work: No. Bathrooms I <br /> 2. New Building Details _ <br /> New Building .......... Type of Construction: No. Bedrooms .......... ra: -0 <br /> Addition Septic Tank Size Gals. .......... <br /> .......... <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... i <br /> Filling .•........ Height............. Stories ............... 4a. Absorption Field Site: ?(� <br /> Moving .......... Area Soil Type .................................... r <br /> Grading .......... Slope .......................................... �« <br /> Mobile Home 3. Use (describe exactly, 1 -family <br /> Perc. Rate ................................... <br /> Privy ••. .... home,garage, motel, etc.) Dry Well ,y <br /> Well Seepage Trench <br /> ..... .... ................ <br /> Subdivision „•,•• Privy .......... �. <br /> Seepage Bed <br /> ..... <br /> ---------------------------------------------------------------------- <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road \ :..1 s L <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 v <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. lr� <br /> ---------- ------------- -------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> OV..... ft. x ...CQ.q ft. — .......� ......... sq.ft. ........ fi. a .. V.l LlG lr <br /> 0 <br /> 0 ct <br /> �L` <br /> 0" <br /> �� <br /> w e <br /> o <br /> CD <br /> I <br /> i `D <br /> )j cn r -D Cn co z <br /> c m m <br /> \ CD m c CD <br /> / m. N Q a< — ';Q <br /> / a "' H:C g m <br /> Z O O ID T <br /> r o <br /> G- <br /> p <br /> ...... ........R.... ........0..,/ o <br /> Signature of Owner or Agent Date ) C <br /> x al <br /> Remarks n <br /> ........................................................................................................................................................................................ <br /> to ' <br /> ........................................................................................................ ......................... :I <br /> . : cn ,Nm <br /> Inspection Date ....................................... o 0 0 o cn <br /> ....... '��....................... m <br /> Zoning Ad inistrator o o�o 0 o cn <br /> ROTE: 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 /> vith 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 />