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3urnett County Office of Zoning Administrator , 0 o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. _ <br /> f0 THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as ; :Q <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m <br /> Jrdinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 0--� ,S'�1 . .. :. .. .... ' � :'� .• ........... ............................. <br /> _ a , <br /> H h : <br /> JWNER I ase print) Cn TRACTOR or SURVEYOR or AGENT CD <br /> . = <br /> A. ,......1 �.......S.`!� d�............................. <br /> 4DDRESS A DRESS <br /> ............................................... <br /> ADDRESS ADDRESS <br /> ............. .P..H.. ... <br /> ............................................. J <br /> ?HONE ,••• ONE..... � •(per` <br /> ........................................................ WELL'E'"L....D.RI....LL......ER..................................................................... :W <br /> PLUMBER <br /> .......... <br /> ADDRESS ADDRESS CD o <br /> 0 <br /> PHONE, < <br /> PHONE................................................................................. ................................................................................ z r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 0 <br /> 1. Work: 2. New Building DetailsNo. Bathrooms <br /> """"" o <br /> New Building No. Bedrooms -0 <br /> Type of Construction: ""' "" m <br /> Septic Tank Size Gals. <br /> Addition """"" <br /> Sanitary .......... Size .............. ft.. x .............. ft. <br /> Filling .......,., Height.........:... Stories 4a. Absorption Field Site:...............: . <br /> ............. Soil Type .................................... r <br /> Moving Area ............................. o <br /> Grading Slope .......................................... h <br /> Mobile Home ...•,••,.. 3. Use (describePerc. Rate ................................... r <br /> . exactly, 1 -family <br /> Privy .......... home,garage, motel, etc.) Dry Well �- <br /> Well Seepage Trench .......... i <br /> .................................................... <br /> Subdivision .... Privy Privy <br /> .................................................. <br /> Seepage Bed .......... `l! <br /> ---------------------------------------------------------------------- } I (n <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- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING y <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS.. ?' <br /> 5. Lot Size: Fig: A. 6. Location: ' <br /> 3` R1 <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... E <br /> C <br /> �� 1 0 <br /> � 0 0. <br /> _ <br /> 0 <br /> N <br /> T :—Z <br /> CD <br /> Z <br /> 0 <br /> n. -CD <br /> CID <br /> cri m W CD <br /> — = <br /> v1 < <br /> p H H •< in m <br /> Z o -'tD ID <br /> ° AGO �' 3 <br /> Oa m <br /> ° ......... ao c_ <br /> ..... ........ .... .......... . . . . . . . <br /> Signature of Owner or Agent Date �* <br /> X <br /> Remarks p <br /> m <br /> CD <br /> .......................................................................................... ............................................................................... <br /> ...................................................................................................:....... ......... T <br /> ............. .................................................... . Q <br /> • p:4 000 o m <br /> Inspection Date ....................................... ....... ........ c \ 1� 0 0 0 0 0 o m <br /> Zoning Ad nistrator ° 0 0 0 0 0 0 cn <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 he made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND 'APPROVED. <br />