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i <br /> Burnett County Office of Zoning Administrator W C 0 o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d A• 3 <br /> o <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 CCD �1 <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. a <br /> N <br /> a <br /> r ,uo ✓ ................................................ ! .... '.... ... ?!u....................................... C <br /> k� <br /> R (please rint CONTRACTOR or SURVE R or AGENT a `�° <br /> ............................................................. m <br /> ADDRESS ADDRESS v <br /> ....................................................................... A.....RE... SS'S"S. ........... <br /> ................................................................ <br /> ADDRESS DD <br /> .................................................. PH..ONE....................................................................................... � f <br /> PHONE <br /> ......................................................................................... <br /> PLUMBER WELL DRILLER <br /> 0 <br /> A..... 'E'S"S.............................................................................. <br /> ADDRESS DD..R. ES C o <br /> r+ < <br /> ........... z o r <br /> PHONE PHONE <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building No. Bathrooms """""Details o <br /> New Building .......... Type of Construction: No. Bedrooms L <br /> Addition .......... .................................................... Septic Tank Size Gals. <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... <br /> Filling .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> SoilType .................................... <br /> Moving Area o <br /> .......................................... Slope <br /> Grading .......................................... <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... _ <br /> Privy .......... home,garage, motel, etc.) Dry Well .......... . <br /> Well Seepage Trench .......... 1 <br /> .......... .................................................... <br /> Subdivision Privy .......... <br /> E <br /> Seepage Bed q_� <br /> -----------------------z----------------------------------------------- L c -A <br /> Location of proposed structures and existing structures,well,sewage systems,roads,etc.,should be sketched in Fig. A. Include road 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- 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 o' <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ft. x ft. sq.ft. <br /> Cn <br /> N O� <br /> 0 <br /> 2. �► <br /> 0 <br /> 0 <br /> z <br /> 0 <br /> d <br /> cc <br /> m <br /> -0 Cn w z <br /> cfDi C CD <br /> to < `—° � = <br /> ED. N Q �< <br /> cn < 0 <br /> Z pH < cc F <br /> CID m <br /> o _ <br /> t�o <br /> .......... ........... .................................... `�.'/ .................... ' <br /> .. ........ .... .... <br /> Signature of Owner or Agent Date <br /> Remarks T <br /> 1C <br /> . ................................... <br /> Inspection Date ....................................... ®� ........... e o 0 0 C o L" <br /> g...... . ... ... . ........................ 000000 <br /> Zonin A inistrator 0 0 0 0 0 0 <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 />