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Burnett,County Office of Zoning Administrator Cn d o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT h' <br /> TO THE-70NING 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 UseCDc x{xA•(' <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 Cb <br /> a \\ ?W <br /> OWNER (please print) CONTRACTOR or SURVEYOR or GENT M CD <br /> a <br /> .......... <br /> ADDRESS ADDRESS , <br /> ADDRESS......................................................................................... <br /> ADDRESS <br /> i� <br /> PHONE PHONE <br /> .... ..................................................................... <br /> DRI LLER.. <br /> PLUMBER WELL <br /> p <br /> ADDRESS ADDRESS <br /> m L� <br /> rr < <br /> � o <br /> ............ — <br /> PHONE PHONE <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> D <br /> 1. Work: 2. New Building Details No. Bathrooms .......... o <br /> New Building ..••...... Type of Construction: No. Bedrooms .......... -a <br /> CD <br /> Addition <br /> .......... .................................................... <br /> Septic Tank Size Gals. <br /> Sanitary .......... Size ft. x ft. ......•••• '• <br /> .............. .............. . . . . <br /> Filling .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Type Soil T e .................................... r— <br /> .......... Area ........................................... <br /> Grading .......... Slope ........................................ o <br /> .. �+ <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 /> --------------------------------------------------------------------- <br /> cn <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road :M <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 5 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. `—' <br /> o' <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x ft. <br /> s <br /> s� <br /> N h' <br /> WJAI ° �v <br /> o :W <br /> C N <br /> - s <br /> I I yin � �. <br /> TI :W <br /> CD <br /> L/ J OZ a <br /> CD <br /> m oo Z <br /> �. fD C CD <br /> v'D QI <br /> p m <br /> rtFZ O6071 <br /> o <br /> O Y C.O <br /> �1) CD m <br /> -. .-. - ............... o y : p <br /> signature of Owner or Agent Date 0 C <br /> X i <br /> lemarks ................ -n •r v <br /> ........................................................................................................................................................ m W <br /> ....................................................................................................................................................................................... E» <br /> ................................................................................................................ //................................ V 'I� D <br /> nspection Date ....................................... / ' ... 0 o 0 0 o cn Mn <br /> 0 <br /> Zoning Admini ator c ID I° o 0 0 0 0 o cmi) <br /> OTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> afore 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 /> g 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 />