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<br /> Burnett County Office of Zoning Administrator Cn 0o
<br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3 M .�
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<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 C [ i
<br /> Ord ihance, Sanitation Code, and with allotherapplicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a (� :!
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<br /> O(�NER'i'y(please print) �7 CONTRACTOR or SURVEYOR or AGENT
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<br /> ADgRES� ADDRESS i
<br /> ADDRESS ADDRESS
<br /> PHO ................................................................................ .PHONE................................................................................
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<br /> PLUMBER WELL DRILLER ,\
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<br /> ADDRESS ADDRESS :� N O
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<br /> .PHONE....................................................... ...
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<br /> DESCRIPTION 4. Sanitary Facilities: o ° 'w-?
<br /> No. Bathrooms 0
<br /> 1. Work: 2. New Building Details """"" ` o [ it
<br /> New Building .,..,,,,.. Type of Construcy'pn� No. Bedrooms ..........
<br /> Addition ,,,,,,,._.;Q,,,,f�/,S,/.�,,ry, ,,,,,,,,,,,,, Septic Tank Size Gals. ......Y V
<br /> Sanitary Size .............. ft. x .... ....... ft. /*Po
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<br /> Filling Grading ,,.,,,,,,, Height............. Stories ............... 4a. Absorption Field Site:
<br /> Soil Type ....................... ... ...
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<br /> Moving .......... Area ........................... ............... o
<br /> Mobile Home .......... Slope ..........................................
<br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ...................................
<br /> Well .......... home,garage, motel, etc.) Dry Well .......... i
<br /> Subdivision Seepage Trench .......... ''
<br /> Camping Unit .......... . ...... ......................................... Privy pv'yi
<br /> Seepage Bed !.81rd.y ks .
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<br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road
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<br /> setback, side and back yard dimension and location and setback from all bodies of water. If property Is located at a highway inter- 9- ° (_
<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. t ¢ o a
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<br /> 5. Lot Size: Fig. A. 6. Location:
<br /> ................ ft. x .............. ft. — ............................... sq. ft. ...............................................................................
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<br /> Signafure of Owner or ent Date C
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<br /> Remarks
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<br /> ............... .. 'Ym ?J.. '.'/✓"-1.- :1r:�ff....................................... . ........... EOt. . .
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<br /> Inspection Date .lf... 0..-d.S..`..... ...... ... .......... . . . . . i S 'o P' rmri
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<br /> Z i n g Administrator 8 8 S S S S ti
<br /> NOTE: A preliminary site inspection must he 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 it 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 Administratol .
<br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED.
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