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Burnett County Office of Zoning Administrator M -i Z <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 o <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use CD c V Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 M <br /> ��/ <br /> OWNER (please print) ......................................................................................... H m O <br /> CONTRACTOR or SURVEYOR or AGENT <br /> CD <br /> CL <br /> ADDRESS �07s'ADDRESS <br /> ................................................^............ <br /> ADDRESS ......................................................................................... <br /> ADDRESS <br /> s.-. ..7.�.�f.................g . <br /> ..... <br /> PHO E ....................................................................................... <br /> PHONE •� <br /> PLUMBER ......................................................................................... •� , <br /> WELL DRILLER <br /> 0 ADDRESS ......................................................................................... <br /> ADDRESS CD' O <br /> 0 < <br /> 0 O <br /> .................................................................... —. <br /> PHONE ....................................................................................... O O o <br /> PHONE z H <br /> DESCRIPTION r <br /> 4. Sanitary Facilities: �; o <br /> 1. Work: No. Bathrooms : <br /> 2. New Building Details 3; o <br /> New Building Type of Const uction: No. Bedrooms �: co ; <br /> Addition ••.• ..........W D� Septic Tank Size Gals. ....... .. F' <br /> Sanitary .......... <br /> .......... Size .............. ft. x ....��.... ft. A:Filling .. ....... Height Stories ....( 4a. Absorption Field Site: <br /> Moving Area Soil T � <br /> ....Z. Type .................................... r <br /> .. ............................ Slope �• <br /> o <br /> Grading .......................................... <br /> .......... <br /> Mobile Home Perc. Rate ................................... <br /> .......... 3. Use (describe exactly, 1 -family : <br /> Privy jo <br /> „ .,.,••• home,garage motel, etc.) Dry Well o <br /> Well Dp rC Seepage Trench <br /> ....T................ ............................ ; <br /> Subdivision Privy o <br /> .......... .................................................... <br /> SeepageBed ...•......-------------------------------------------------------------------- <br /> Cn <br /> W ; <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road �p setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- O a <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. H' <br /> ----------------- _________ o <br /> 5. Lot Size: 76 Fig. A. 6. Location: t� <br /> �(S.Q...... ft. x .............. ft. — ............................... sq.ft. ............................................................................... <br /> fn <br /> CD <br /> } V� 0 <br /> N <br /> O j(.' <br /> cn •W <br /> 00 <br /> a <br /> -n <br /> oCD <br /> C <br /> i <br /> .Q <br /> �o cn cn <br /> cv �. � m Z <br /> 0 c m <br /> v1 < C: <br /> Z C E; CD <br /> o _. <br /> :O 0 <br /> o � <br /> � � <br /> nature of O er or Agent Date V <br /> o c <br /> x 70 <br /> marks, '. .. ..1.as9.3.................................................................................................................... <br /> T 10 <br /> CD <br /> .................................................................................................... ........................ m <br /> pection Date ....................................... ..............9............... o 0 0 0 o cn m <br /> 0 0 0 0 0 o m <br /> Zonin Administrator 0000000 <br /> TE'. A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> ire construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build <br /> until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> i 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 />