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Burnett County Office of Zoning Administri for 6n 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 2 0 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements o the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and <br /> regulations of the State of Wisconsi f / n <br /> CL <br /> nd Ct Tf" . q <br /> ...� ?.c .as......... ' . h. ......................................... - <br /> r4h r1Y o <br /> OWNER (please print) CONTRACTORbr SURVEYOR or AGErdf <br /> 1:, .1.!......g, ............................... ... . . . . . ..................................................................... ....... <br /> ADDRESS ADDRESS <br /> ADDRESS ADDRESS �� S <br /> I j <br /> PHONE................................................................................ .PHONE..................................................................... .... <br /> H <br /> . . :..................................................... ............. ...................................................................... ....... <br /> PLUMBER WELL DRILLER: <br /> ........................................................................................... .................................................................................... ....... n O <br /> ADDRESS ADDRESS m 0 "r,C <br /> ........................................................................................... <br /> ...PH....O..NE........................................................................... ....... Z r <br /> PHONE r <br /> DESCRIPTION 4. Sanitary Facilities: o o <br /> 1. Work: 2. New Building Details No. Bathrooms ..... c <br /> xNo. Bedrooms <br /> New Building Type of Constr coon: �r ••••••" R <br /> Addition ,,,, ""`� Septic Tank Size Gals. . ........ <br /> .......... ......... .. ... ... <br /> v `.i11.... ft. G CL f <br /> Sanitary ..C..... Size .... . . .. ft. x ..... 4...... r� <br /> Filling/Grading .......... Height..... . .. .. Stories ...I.. 4a. Absorption Field Site: (� <br /> stn .+^ .... <br /> l.y:(T.Q..S�jA .�:E::. Soil Type .......................... K r i <br /> Moving .......... Area ...... O <br /> Mobile Home Slope ................................. ........ 1i <br /> .......... .. <br /> Privy .......... 3. Use (describe exact), „�1"f�i Perc. Rate .......................... ........ � <br /> Well ,,........ home stage,motel, c.) Dry <br /> m Well . ........ _ !•� ft 0 <br /> 1...... .. . . .�.... .. . ..... <br /> Seepage Trench . z <br /> Subdivision Privy . ....... <br /> Camping Unit .......... .................................................... Wi <br /> � <br /> Seepage Bed . ........ <br /> ------------ --- --- --- — -- -- L <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in F g. A. A <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is loc ed at '[l�f \ <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the interse tion. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. :C> <br /> _____________ ___ <br /> _____________________________________________________ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> h <br /> ................ ft. x .............. ft. — ............................... sq.ft. ...............N.).C.C� .J1.1��..... ........... ....... � L, � <br /> C7 <br /> C 1 <br /> IN 0 <br /> O c� <br /> 0 <br /> 0 <br /> 0 <br /> s <br /> 1 <br /> Z <br /> o <br /> I \ mvtnr Dm m 'p <br /> n �C n S. S. nI <br /> m Nn� —� am any <br /> o.. 6<, : '�2 C N M o ; <br /> O m y 0 0 m <br /> ZOO : � � D 1 <br /> oN� vin ; 9 <br /> 6 v <br /> 2m D <br /> Signat a of Owner r Agent Date $ <br /> m; N <br /> Remarks n <br /> ........................................................................................................................................................................................ U. O <br /> ...................................................................................................... ... ...................... .. ......... . .....Ui. . $ $ <br /> Inspection Date N N J N <br /> Zoning Administra r v 8 8 8 8 8 <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary f 3cilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this apl dication 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 ben issued. A permit may be <br /> revoked it 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 ANDA 3PROVED. <br />