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6mPcrr � <br /> Burnett County Office of Zoning Administrator Y,' q�q <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT • 3 , <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and + `k <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the tp <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and <br /> regns of the State of Wisconsin. <br /> Dry. S k ..� ......... 'a <br /> .............. l ease.............. ............................ ............................................................................................ � m <br /> OWNER (Please print) � CONTRACTOR or SURVEYOR or AGENT <br /> 1 744 <br /> �a r n <br /> . .. ....:................... . . ........ ............................................................................ <br /> AD R SS ............................ ADDRESS m <br /> .R.% .. .s.a.. ....�..�...........:��rE.9...... ............................................................................................ <br /> ADDR SS ADDRESS <br /> ........................................................................................... ............................................................................................ t <br /> PHONE PHONE r✓� <br /> ..................................................... ..... ...................................................................................... .� <br /> PLUMBER WELL DRILLER <br /> O <br /> AOORESS ADDRESS m Ll <br /> o <br /> ........................................................................................... .PHO-H-O-NE..................................................................................... O .i <br /> PHONE Z N r <br /> DESCRIPTION 4. Sanitary Facilities: P o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details •• ••• c <br /> New Building .......... Type of Constructi&o_: No. Bedrooms .. .... i <br /> ! !f r <br /> Septic Tank Size Gals. : <br /> Addition " \ i <br /> ........... t.�.......... <br /> Sanitary ..�. ... Size ft. x ft. ••• •• <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: r t t <br /> Moving Area Soil Type .................................... r <br /> .......... .............................. ...... .. <br /> Mobile Home ... $IOPe .......................................... O <br /> .......... <br /> Privy <br /> .......... 3. Use (describe exact) ,'1 •famil <br /> Perc. Rate ................................... m <br /> Well , ........ home,garage, motel, ey {D <br /> Dr Well ......... <br /> Subdivision .......... Seepage Trench .......... o i <br /> .................................................... 1 <br /> Camping Unit ,,,,,,,,,, Privy <br /> ••• a•• ,,, <br /> ,R G .'J <br /> .................................................... Seepage Bed <br /> --------------------------------------------------------------------- ' I i m <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. � :Y <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at :.-ice <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. �pp[� 7MVV < <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. `o <br /> ----_ —___ _________ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................... i <br /> i� <br /> n <br /> N 0 <br /> O <br /> J <br /> R, <br /> 0 <br /> O <br /> N <br /> T <br /> r � <br /> M in 0 > W W a <br /> m. �n•< - nm aa9 <br /> o < d C <br /> S N •G0 p rp !O <br /> » e : s <br /> so <br /> { W l o <br /> n : m <br /> ...... .......... . ....................................................... ...................................... <br /> Signature o caner or Agent Date <br /> S : <br /> w <br /> a <br /> m •• <br /> N <br /> . ... r ...'....fQ . . . rO ' $ <br /> �N <br /> ..... ............................................................................................. ... . ....... . . . ........ . ..l.............. <br /> uInspection Date ....................................... ........... m............� ..�j. ......... <br /> ZoningAdmstratdp.Tel888888U1 <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this application before a permit will <br /> be issued. Do not purchase or install a septic tank, do any plumbing or start any building until a permit has been issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />