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Burnett County Office of Zoning Administrator d - o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT rt 0 � <br /> " <br /> d ' <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < o 0 <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land UseCD <br /> m <br /> Ordinance, Sanitation Code,and with all other applicable C unty Ordinances and the laws and regulations of the State of Wisconsin. R o_ :(Z)f <br /> r+' . <br /> f / — a :�? O <br /> Wr' .. �C ? !1 �n !► q �r. ...................................................................................... N <br /> OWNER (pleas printI ` CONTRACTOR or SURVEYOR or AGENT a <br /> .............................. .................................................... ............................................................................................ Qh� <br /> ADD ESS ADDRESS :Q <br /> Piz 4 4 <br /> D / �y <br /> ADDRESS ADDRESS <br /> .................................... ...... ............................................... ............................................................................................ <br /> P� PHONE <br /> .............. ............................................................ ............................................................................................ :p <br /> PLUMB IF WELL DRILLER <br /> ................. <br /> .......... <br /> ADDRESS A. DDRESS <br /> 0 o n <br /> h ^b <br /> o' s <br /> PHONE PHONE <br /> Z N r <br /> DESCRIPTION 4. Sanitary Facilities: / _ ° o ° .� <br /> 1. Work: 2. New Building Details No. Bathrooms :a o <br /> t <br /> No. Bedrooms <br /> New Building .......... Type of Construe i�o�n:^ V <br /> .��.,�Is�GT! Septic Tank Size Gals.Addition pSanitary ..v Size .............. ft. x .............. ft. <br /> Filling Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area Soil Type .................................... :L.� r <br /> ........................................... <br /> o <br /> Grading Slope .......................................... <br /> .......... <br /> Mobile Home Perc. Rate ................................... <br /> .......... 3. Use (describe exactly 1 -famil <br /> Privy .......... home,garage, motel, etc.) y <br /> Dr Well .......... :0 <br /> Well ... Seepage Trench .......... <br /> Subdivision : ................ Privy <br /> ............................... ... <br /> Seepage Bed > <br /> N <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- s �� <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING 6 :� <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. © p' :a - <br /> ----- Q c vl <br /> 5. Lot Size: Fig. A. <br /> ................ ft. x .............. ft. — ............................... sq.ft. <br /> N <br /> m <br /> n <br /> r+ <br /> N O <br /> O 7 <br /> N <br /> r1 <br /> Q <br /> CD <br /> tp <br /> CD <br /> cnr �g w <br /> CD c m 2. m c <br /> '0 cn < <br /> M <br /> oN�N <br /> Z O o CD <br /> o <br /> N <br /> O � <br /> • p- S— p CD <br /> ° p <br /> v 0 C <br /> .... . . ......... ............. <br /> ................... o <br /> Signature of O er or Agent Date ,i X m <br /> Remarks ........................................................................................ co <br /> CD :t" <br /> ........................................................................................................................................................................................... <br /> ........................................................................................................................................................................................... fe <br /> 7 � , 'n <br /> Inspection Date ....................................... (!/:..P4.:... G .............. o 0 C o m <br /> ......................... <br /> Zoning Administrator • Cn <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 />