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Burnett County Office of Zoning Administrator o / o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3. <br /> o <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 m C <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 M <br /> O <br /> �.�Z?...... ..... /8. � ... .............................. .............-......................................................................... <br /> OWNER (Please print) � f'Y[J CONTRACTOR or SURVEYOR or AGENT o. <br /> .............. , <br /> ADDRESS ADDRESS <br /> 'U <br /> ADDRESS ADDRESS <br /> ........................................................................................... ............................................................................................ <br /> PHONE ................................................................ PHONE <br /> ................... ............................................................................................ <br /> PLUMBER WELLDRILLER <br /> .......... <br /> ADDRESS ADD.. <br /> .... ...R...ESS...................................................................... / <br /> . . . .. .......................................................................... <br /> .......... <br /> . ..... .................................. ........... ............... ............... p' o` <br /> PHONE �I-IONE Z <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details d <br /> New Building .......... Type of Construction: No. Bedrooms .......... <br /> m <br /> AdditionSeptic Tank Size Gals. .........mss, p <br /> e . <br /> Sanitary Size ft. x ft. ..... ••" <br /> FillingtGrading ,,.,...,., Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving ....�. Area Y Type .......... I ?� o <br /> ......................................... <br /> .. SoilT e .................................... <br /> Mobile Home Slope ° .. <br /> Privy 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> epage <br /> Subdivision .......... ....... .n ! 2e'....... /........ Seep 9ellBednch .......... W i� <br /> We .......... home,garage, motel, etc.) <br /> Camping Unit ,,,,,,,,,, Y a'VU <br /> ------------------------ --------- ------ es � M„ <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc.,should be sketched in Fig. A. Include road iY ? ' 1 <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter <br /> �along a <br /> section, show the intersecting highways and the setbacks requiredthem and at the intersection_ CLEARLY LABEL EXISTING <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. O H <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size •+�� n�1 C J� Fig. A. 6. Location: _ - i �1 <br /> ..l6/..t ..... ft. x .C.7.LtZ.1A. . — .. sJ.�.r�t.QOC-t.. sq. ft. ................ ..�/ 44? ...../.UQ.Al....:5!.?J(... <br /> tooM^ N <br /> t ti <br /> N o <br /> O � � <br /> F <br /> arm � <br /> a <br /> srri <br /> b <br /> h • l: 7aNr .y <br /> F <br /> 0 <br /> m Z <br /> TO <br /> StAiC van '— o O <br /> et �1 a � n - m y n <br /> m <br /> .... . . .....may.. . .... <br /> m <br /> Signature of Owner o Date ° C <br /> X M <br /> Remarks ............................................................................................................................. m............................................ „ ; p <br /> m . <br /> on <br /> ........................................................................................................................................................................................ A) <br /> ...................................................................................................... .. .................................. ............ <br /> vi . <br /> $: <br /> H m <br /> InspectionDate ....................................... ................../-..... ............ ....�!`.:........................ : I rr7 <br /> Zoning Administrator r-J $ $ $ $ $ $ rn <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 />