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Burnett County Office of Zoning Administrator v Y(D o z <br /> 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> TO THE ZONING ADMINISTRATOP': Thtvu%dersigned 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 - c V <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. n o <br /> .... ��.. ................................. <br /> ....................... <br /> � .: .. - .. . .. <br /> OWNER (please print) CONTRACTOR eor SUR YOR or AGENT Q M <br /> ..... . ............ - .,... ./........................................................ <br /> C- <br /> ...... <br /> ...... ......... ...... <br /> ADDRESS AD.�.�..DRESS °) ' <br /> .................................................................... <br /> ................. : : : <br /> ADDRESS ADDRESS <br /> ........................................................................ ......................................................................................... <br /> PHONE PHONE <br /> .......... <br /> PLUMBER WELL DRILLER W <br /> ................. ........................................................................ ......... <br /> ADDRESS ADDRESS <br /> 0 o <br /> ........................................................... N......................... :z r+ <br /> PHONE PH..O...NE � r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details ......•••• 0 <br /> New Building .......... Type of Construction: No. Bedrooms <br /> CD <br /> Addition Septic Tank Size Gals. ' <br /> Sanitary .......... Size .............. ft. x ft. ......•••• <br /> Filling .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> MovingArea Soil Type .................................... r........................4.................. <br /> g <br /> Slope ° <br /> Grading . ........ p <br /> Mobile Home .•........ 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Privy .......... home,garage,motel, etc.) Dry Well <br /> Well Seepage Trench .......... I <br /> .......... . . <br /> Privy <br /> Subdivision f/ <br /> i <br /> Seepage Bed .......... <br /> ---------------------------------------------------------------------- S� :ln <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road I O <br /> a <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 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. �' `0 <br /> O <br /> -------------------------- -- - <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x ft. s ft. <br /> — q. ............................................................................... <br /> Cn <br /> N O� <br /> o <br /> 09 ID 3 <br /> 0 <br /> N <br /> -nCD <br /> Z <br /> O <br /> v <br /> coZ <br /> m C m <br /> CD_ <br /> a cn< C. �' S' C � <br /> pv . G co M <br /> o ��O <br /> � L <br /> 0 <br /> %..."-�.� p <br /> Signature of Owner or Agent Date r ` C <br /> X <br /> Remarks ......................................................................................................................................................................... m <br /> C <br /> ........................................................................................................................................................................................ -- <br /> ;p <br /> � : 00000cNr, lm� <br /> Inspection Date ....................................... : 0 0 0 <br /> Zonin dministrator 0 0 0 0 0 o cn <br /> IOTE: 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 /> ig until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> iith 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 />