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Burnett County Office of Zoning Administrator fl° c <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3. <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the ,$ c <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 ii <br /> regulatio s fthe State of Wisconsin. <br /> Z.1 <br /> .C-C 4...h....S..... k�......... .............................................'0-r-.................................... ..... n <br /> OWNER p ase print) CONTRACTOR or SURVEYOR AGENT m <br /> .. . . l'. / . ...... . . ........................................................................ ..... a i <br /> ADDR 5 ••• •••••• ADDRESS <br /> . . . ................................................................................ . . ...... S-S- ................................................................... <br /> ADDRESS ADDRESS <br /> ..................................................................................... ...... <br /> Tt. <br /> PHO PHONE J ic� <br /> .... .... ... ... ................ .......................................... . . . ........... . ................................................................ ...... :O <br /> PLUMBER WELL DRILLER CC'Q !7 <br /> 11 <br /> ........................................................................................... . ... .......................................................................... ...... O <br /> ADDRESS ADD..... R..ESS m O :x <br /> 0 O :Ll <br /> ........................................................................................... <br /> _. <, <br /> PHONE PHONE Z <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details /j)04 A J No. Bathrooms o !�v <br /> New Building „.Nc„ Type of ConslLuction: g'x ao'orcf� No. Bedrooms ... S N !) <br /> i <br /> Addition .......... ........... ....•,,,,•••,•^4,.:'.".�........... Septic Tank Size Gals. ... . ;00 . <br /> Sanitary ,,. Size ...�.. ft. x ........ ft. <br /> •. —� <br /> Filling/Grading ,..,,,,.,, Height...........[,'. Stor}' 4a. Absorption Field Site: <br /> Moving Soil Type ............................. ...... <br /> ....... .. Area ........�� : � ......... <br /> E i 'r <br /> Mobile Home Slope ................................... ...... p <br /> Privy .......... 3. Use (describe exactly, t -family Perc. Rate ............................ ...... <br /> Well home,garage, motel,e . Dry Well ... T <br /> Subdivlalonpage Trench Z <br /> ee <br /> ... ...... o <br /> Camin Unit y <br /> p g Priv SU <br /> .......... .................................................... ' <br /> Seepage Bed <br /> ----------------- — — — <br /> -------------- ------- — l.: -- <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig A. C �7 <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is local d at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. N <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. . I p <br /> — <br /> ' <br /> 5. Lot Size: Fig. A. 6. Location: n <br /> ................ ft. x ..:•........... ft. . ............................... sq.ft. ........................................................................ ...... <br /> nT 7 0 <br /> o <br /> J Z <br /> N U) -o <br /> N N n cm co V <br /> Z � � D ' •� <br /> mom . Nn ' <br /> 0 a o 0 <br /> � q......-. .. .`................................. ... - .�?..'.5.. .......... vSignatur or Agent`, Date o <br /> ..................�.�Remarks ......... ..... .... .... .... . .car6 <br /> / mI n <br /> / n p <br /> o . o <br /> b o <br /> ..... ............................... ... <br /> Inspection Date ,,..,.. .. . . .......... ....`� N 8 N o o � m <br /> pe ....................................... . .... ........ g ................... .. <br /> Zonin Ad nistrator 8 88 8 8 8 (n <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary fac lities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this appli ation 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 ors ecificat ions shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APP OVED. <br />