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Burnett County Office of Zoning Administrator ; <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 0 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the .J <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the State of Wisconsin. <br /> m <br /> ....Y...r r ..... .....6P.....:::.................................. le j <br /> OWNER` (lease print) CONTRACTOR or SURVEYOR or AGENT <br /> ..// s <br /> ADDRESS.. ............. ADDRESS . ......,.. .................................................. .d. <br /> .... ...... .:.............. . . . ..... ....... ........................................................... <br /> ADDRESS ADDRESS oT <br /> ....... ..... ...... ..r........:...: ..........I................................. .............:....:::: ................ ................................................... <br /> PHONE PHONE <br /> ........................................................................................... . ...... . .. . ....................................................................... : 1 <br /> PLUMBER WELL DRILLER (X1 <br /> . . . ................................................................................ . .ADDR...... .ES.S............. <br /> ................ <br /> ... <br /> ................................... ........... .O <br /> ADDRESS <br /> 0 o <br /> . . . ................................................................................... . . . . .................................................................................... N' <br /> < <br /> PHONE PHONE Z <br /> DESCRIPTION 4. Sanitary Facilities: P S o �ip <br /> 1. Work: , 2. New Building Details No. Bathrooms ... c :w <br /> New Building No. Bedrooms . '� <br /> Addition Septic Tank Size Gals. .......... S 7 <br /> Sanitary ...... :uj . <br /> ... .... Size .... ... ft. x ..:..�..... ft. <br /> Filling/Grading .......... Height...:`; . .:.. Stories .f::'....... 4a. Absorption Field Site: <br /> Moving Area '^Yo Soil Type .................................... <br /> .......... ........................................... <br /> Mobile Home Slope o <br /> .......... <br /> Prier 3. Use (describe exactly,'1 -family Perc. Rate ................................... Ti <br /> -watt— -.:?!rc home,garage, motel, etc.) Dry Well .......... i <br /> Subdivision j <.;,..-:. Seepage Trench <br /> .......... ..... ...................::.*f...7.f,................ ......... o <br /> Camping Unit .......... Privy .. . i <br /> .................................. .......... . .... pY� LL <br /> Seepage Bed <br /> -------------------------------------------------- — �.0•-- <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. t g #n <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located atI t 1 <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. : `— <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. : I o <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. h iI',"-: :•.s..•..."15..:i......................... : I :+'l <br /> v <br /> f <br /> 0 <br /> N <br /> � � W <br /> 0 <br /> a <br /> r , <br /> 0 <br /> P <br /> , <br /> mvrnr > <br /> n d'c, < > > n S. S. m <br /> i T �n•e — n m na S <br /> dCw > > ; <br /> i V• y n � <br /> 0 <br /> r O <br /> Signa�ure of wner or gent Date o ; <br /> 0 <br /> Remarks . -��✓ L -G� <br /> ....../.. ......................................................................................................................................................... a <br /> .............................. L......L�-�:`�.................................. <br /> ......................................................................................................... ...................... ............... o <br /> Inspection Date ..L..-'..1... .` ...... C% J .....A � r a o o N m <br /> / ° m <br /> Zoning Admini ator o g S (A <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 />