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Burnett County Office of Zoning Administrator C -0 - 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ' . <br /> o S <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as H •-4 <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m c J <br /> Ordinare4eel <br /> Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> ......0......J� .lf7..`.e..!^.................. h <br /> y <br /> y : O <br /> OWNER (please print) ,,/ CONTRACTOR or SURVEYOR or AGENT a � <br /> CD <br /> ID4R ADDRESS � <br /> ........ V <br /> ADDRESS ADDRESS <br /> ....Y.A... � <br /> PHONE PHONE tl <br /> ............................................................................ .W...E.........R. IL I'L .....LER.................................................................... <br /> PLUMBER LL D <br /> .......... �' G) <br /> ADDRESS ADDRESS <br /> _ O N <br /> PHONE PHONE <br /> DESCRIPTION 4. Sanitary Facilities: o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details •••'••'••• o <br /> New Building .......... Type of Construction: No. BedroomsCD <br /> Addition .................................................... Septic Tank Size Gals. <br /> Sanitary .....I.... Size .............. ft. x .............. ft. .......... <br /> Filling Height............. Stories ............... 4a. Absorption Field Site: i <br /> Moving Area Soil Type .................................... r `• <br /> Grading Slope .......................................... <br /> .......... <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Privy ...... home,garage, motel, etc.) Dry Well <br /> Well Seepage Trench .......... <br /> Y..... <br /> Subdivision Privy i <br /> Seepage Bed .......... <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc., should be sketched in Fig. A. Include road '~ c <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- a Nc- m <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING y 0 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o' 0 <br /> _ <br /> ------------------------------------ <br /> 5. Lot Size: Fig. A. <br /> ................ ft. x .............. ft. — ............................... sq.ft. <br /> N ^ <br /> r'F <br /> .-n O <br /> V <br /> C <br /> Z = <br /> O <br /> Q (D <br /> Q <br /> 1 <br /> 0 c �.�cu <br /> ti, a Q r <br /> n o cn C <br /> < <br /> l' oy. ; :3 - <br /> Z 05 c° <br /> 1Z Ie..(...... I- <br /> 0 <br /> Signature of Owner or Agent Date <br /> -n x ` r <br /> Remarks .11.�>:.?�! " t..F.4?! �C <br /> ........................................................................................................................................................................................... p �i <br /> ..................................................................................................................................................................................... t - <br /> InspectionDate ....................................... w:. ..:... . . . . ... '? ........................................ 0 0 0 0 o r <br /> Zoning Administrator C <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 />