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ON COMPLITER/SCANNED 6>i, <F rl '/.I . <br /> Burnett County Office of Zoning Administrator U -- 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 R <br /> T'O THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as H :W <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 O. <br /> .� ....... ................... `\Si) <br /> OWNER (Plea a pri t) CONTRACTOR or SURVEYOR or AGENT a m <br /> �\ <br /> .;.4�!�� ......�.. ............................................. 3 ............ a `� <br /> ................................................. d <br /> ADDRESS ADDRESS <br /> i\ i ER <br /> ........................................................................................... .A.......RES.. .... .............................................................................. :\ <br /> ADDRESS DDS <br /> PHONE................................................................................ .PHONE................................................................................ <br /> ........................................................................................... . . . . . . ...................................................................... <br /> PLUMBER WELL DRILLER '� � �� <br /> p <br /> ADDRESS ADDRESS <br /> n o <br /> PHONE PHONE Z <br /> r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> h <br /> Batrooms <br /> I <br /> 1. Work: 2. New Building Details No. •••••••••• i <br /> New Building .......... Type of Construction: No. Bedrooms .......... a <br /> m <br /> Addition .................................................... Septic Tank Size Gals. .......... <br /> .......... <br /> Sanitary .......... Size ft. x .............. ft. •""'•"' ' <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Soil Type ..................... <br /> .......... ........................................... ............... <br /> o <br /> Mobile Home .......... SOpe .......................................... ^ <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Well ....... .. home,garage, motel, etc.) Dry Well .......... <br /> SubdivisionSeepage Trench .......... <br /> ....... .. ............. ...................................... <br /> Camping Unit .......... Privy .......... i i <br /> .................................................... <br /> Seepage Bed .......... <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc., should be sketched in Fig. A. Include road Q <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter o- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING c <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o' <br /> --------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... <br /> sw 0 <br /> 33/- 333 o <br /> )� yi "' I Af <br /> 1 ` 0 <br /> r <br /> 0 <br /> o . <br /> r' ,t m <br /> Jx , <br /> wr rp Z <br /> Z o' a <br /> :W� m <br /> ...................................... . .................................. //— ... —�S — C <br /> o <br /> Signature of Owner or Agent Date <br /> X <br /> Remarks ......................................................................................................................................................................... na m <br /> C v <br /> ........................................................................................................ ................... <br /> II <br /> � ,s � o � o � m <br /> ...................... ................. <br /> InspectionDate ....:.................................. G.Z/.! !.......:..... ......... ...............k J............. . <br /> Zoning Ad nistrator 5 8 8 8 $ 8 $ to <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 fie made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />