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Burnett County Office of Zoning Administrator a -- z <br /> o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < 7 <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use '1 C ^ } <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. <br /> J,i..........�c�1L��P i� <br /> .................... ... <br /> OWNER lease print) CONTRACTOR or SURVEYOR or AGENT m . <br /> 0 <br /> ADDRESS ..... ........... ............................................................................................ <br /> ADDRESS d <br /> . .................................................. .. ....... .... .ADDRESS............................................................................ �b <br /> ADDRESS JJJJ <br /> .... <br /> .PHONE................................................................................ .� <br /> PH E <br /> PLSz � ....6f..nv .............. ... <br /> WELL DRILLER t\ <br /> ...........................?`f <br /> ADDRES . .............................. ............................................................................................ _ <br /> ZZ ADDRESS <br /> o <br /> ............................................................................................ <br /> PHONE PHON <br /> DESCRIPTIONo <br /> 4. Sanitary Facilities: o <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details ....... .. >-.j <br /> 0 <br /> New Building Type of Construction: No. Bedrooms .......... <br /> Addition ...,, ,,,• ,•..,...,.•,,,•„ Septic Tank Size Gals. .......... <br /> v <br /> Sanitary ...Z1.... Size .............. ft. x .............. ft. .......... o <br /> RIIIIng lGrading Height............. Stories ........6...... 4a. Absorption Field Site: ,Sim <br /> Moving .......... Area Soil Type .........6.......................... <br /> ........................6.................. <br /> Mobile Home Slope <br /> b <br /> Privy .......... 3. Use (describe exactly, 1 -family <br /> Fare. Rate ................................. . F <br /> Well .......... home,garage, motel, etc.) Dry Well .......... n G\ <br /> Subdivision .......... Seepage Trench .,........ R <br /> Camping Unit i <br /> , <br /> .......... .................................................... Privy <br /> ....I..... Ju <br /> .................................................... Seepage Bed <br /> __ .......... <br /> -- --------- r .� <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road C i <br /> setback, side and back property y g yEF <br /> yard dimension and location and setback from all bodies of water. If ro ert is located at a highway inter- a <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 /> —————————————————————————————————————————————————————————————————————— W � ' <br /> 3 <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ft. x .............. ft. . ............................... sq. ft. ............................................................................... <br /> : � P <br /> J m <br /> C n <br /> N <br /> o <br /> 3 <br /> � G <br /> 0 <br /> see �► l��r C <br /> � s <br /> t � <br /> el 5 <br /> sC <br /> a [ T c <br /> :C <br /> Z <br /> d � a < '_ . F <br /> NJ C � 01 mt <br /> " <br /> _. <br /> C <br /> o ' a m <br /> a <br /> _ m <br /> :11l 0 <br /> / � m <br /> ..6�-;q:.........Y/..�.� � <br /> Signature of Owner or Agent Date 'U�° C <br /> X <br /> Remarks ..................................................................................... m m <br /> ........................................................................................................................................................................................ Ge <br /> .'ou <br /> ............................................................................................................. ............................................. U. <br /> Inspegtion Date ....................................... ..... .... .. ` m <br /> .. ..... ... ............................... <br /> m <br /> Zoning Ad nistrator $ $ $ $ $ $ fn <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 />