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L `.I, <br /> Burnett County Office of Zoning Administrator C ' o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as v, <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use N <br /> CD c <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 Q_ <br /> _. 0 <br /> mf.3. .fL.T......... k4..l.T.. .Cr................................. ............................................................................................ y <br /> V C <br /> R (please int) CONTRACTOR or SURVEYOR or AGENT <br /> n <br /> ADDRESS ADDRESS <br /> CD <br /> ........ .......... ............................................................................................ <br /> ADDRESS ADDRESS <br /> ................... ..... .... .. . . . <br /> PHONE PHONE. . ' <br /> PLUMBER WELL DRILLER ' <br /> 0 <br /> ...........ADDRESS. .................................................................... <br /> ADDRESS m � <br /> 0 O< <br /> .............................................................................. ............................................................................... p ,rt. . . ..... ............. : <br /> PHONE PHONE <br /> z H r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms � <br /> 2. New Building Details ......n•••• o <br /> New Building Type of Construction: No. Bedrooms .rZ... <br /> Addition 4 Septic Tank Size Gals. .......... <br /> Sanitary .......... Size ft. x ft. ......••••.............. ..... ........ . . . . <br /> Filling .......... Height............. Stories ............... 4a. Absorption Field Site: c <br /> t~ • r <br /> Moving <br /> .......... Area ......................................... Soil Type .................................... ° <br /> Grading Slope .......................................... <br /> .......... <br /> �* <br /> . : <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Privy .......... h&ne,garage, mot I, etc.) Dry Well .......... <br /> Well Seepage Trench .......... <br /> .......... ...e <br /> Subdivision „••••„ Privy W <br /> ... ntrr-�r�aJ.............. <br /> Seepage Bed .......... tni <br /> -------------------------------------- ------------------------ �� cn <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road <br /> Q <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 /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. j� N <br /> o' <br /> ---------------------------------- --- <br /> 5. Lot Size: Fig, A. 6. Location <br /> ft. x ft. s ft. <br /> ............. — q. <br /> m <br /> n <br /> r« <br /> N O <br /> O <br /> 7 <br /> o U <br /> T <br /> CD <br /> �) t Z <br /> t <br /> to <br /> Co <br /> cc1 <br /> `I y D N r: <br /> tZ <br /> CD 0) —• — <br /> 'o to < C 7 <br /> 3 <br /> CD <br /> m <br /> Signature of Owner or Agent Date ° <br /> X <br /> Remarks -n M <br /> 0 <br /> 00000cnm <br /> Inspection Date ....................................... g.... ........ .... o: 0 0 0 0 0 0 � <br /> Zonin Admi strator 0 0 0 0 0 0 (n <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> this application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> with 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 />