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<br /> Burnett County Office of Zoning Administlrator 0 0
<br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ; 3
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<br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and loc ted as < N 0
<br /> shown herein. The undersigned agrees that all work shall decade in accordance with the requirements of the Burnett County Lad Use e
<br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wis orio_
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<br /> OWNER (please..print) CONTRACTOR of SURVEYOR or AGENT m n;
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<br /> AED�E�S�S� ( /�, W ADDRESS ov
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<br /> ADDRESS ADDRESS �
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<br /> PHONE PHONE
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<br /> PLUMBER WELL DRILLER
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<br /> ADDRESS ADDRESS o
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<br /> PHONE PHONE Z N
<br /> DESCRIPTION 0 :O
<br /> 4. Sanitary Facilities: o °
<br /> 1. Work: No. Bathrooms v
<br /> 2. New Building Details ' o
<br /> New Building Tylp'e`of Con tructio ,1 No. Bedrooms .......... z
<br /> Addition ,,,� ,,,�!!'^,/„'„ ,,,7„ /�S�/f”/1 y Septic Tank Size Gals. ..........
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<br /> Sanitary .......... Size ..D. �!.,Z ft. x Y'� .••.ft. ......•..•
<br /> Filling/Grading ,,.,.,,,,, Height....k....... Stories .....1......, 4a. Absorption Field Site:
<br /> Moving .......... Area Soil Type .................................... r
<br /> ........................................... Slope Mobile Home o
<br /> Privy .......... 3. Use (describe exactly, 1 - family Perc. Rate ........................ ..........
<br /> Well .......... home,garage, motel, etc.l Dry Well .......... i
<br /> See a e Trench ..........
<br /> Subdivision ,,,,,,,,,, /•/U ••T//I/(i. 'f”-Kr/,�/ QyJ P 9
<br /> Camping Unit .......... ....../.1./.cg...T!! �^ ............. Priv
<br /> Seepage Bed
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<br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Inclu e road ..�
<br /> setback, side and back yard dimension and location and setback from all bodies of water_ If property is located at a highwa Inter- °-
<br /> section, show the Intersecting highways and the setbacks required along them and at the intersection_ CLEARLY LABEL EXI TING
<br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS.
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<br /> 5. Lot Size: Fig.
<br /> A. 6. Location:
<br /> ................ ft. x .............. ft. — sq. ft. I i E i
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<br /> Sijgnature of caner or Agent Date »
<br /> Remarks ... ... �� /„`� m x m
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<br /> Inspection Date ....................................... .. ... . . l..!.. .tF(l/1�.C... . ... ...... u N o u�r 'o ren m
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<br /> Zoning Administ for $ $ S S $ $ N
<br /> NOTE: A preliminary site inspection must be made and site approval granted on all strictures ii volving sanitary facilities
<br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolatioi test must be attached to
<br /> this application before a permit will be issued. Do not purchase or Install a septic tank, do any f)[L robing Or start any build-
<br /> ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the in ormation conveyed here-
<br /> with is found to exist. Changes in plans or specifications shall not be made without approval of t to Zoning Adm inlstratol .
<br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE HAND APPROVED.
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