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Burnett County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 6 <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 ,$ <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 Wi con in. 3• <br /> 1.�. .. ........ ... ............. ... ... ............................................................................................ n <br /> DWNER (please print) CONTRACTOR or SURVEYOR or AGENT <br /> O <br /> 3.G ................ y S �. <br /> fi <br /> � - <br /> ADD ADDRESS <br /> ✓P ST.P... <br /> ............. !:. .. G� .� ........,................................................................................... <br /> ......... <br /> ADDRESS ADDRESS ?p <br /> ........................................................................................... ............................................................................................ <br /> PHONE PHONE <br /> ........................................................................................... . ...... . .. . ...................... ............................................. <br /> PLUMBER WELL DRILLER.. .. <br /> p <br /> ADDRESS ADDRESS m L'f <br /> ........................................................................................... . ................................................................................ : o <br /> PHONE 'P-H-0-N—E- .............. <br /> ' <br /> DESCRIPTION 4. Sanitary Facilities: P o <br /> 1. Work: 2. New Building Details No. Bathrooms .......... c <br /> New BuildingT No. Bedrooms <br /> Type natructio ..•••.•.•• R <br /> Addition !„•••••.•, ,,,,,,,, ``'��`--� Septic Tank Size Gals. .......... , <br /> Sanitary .......... Size .... . ...ft. x ..QC.. ... ft. .......... <br /> Filling/Grading .......... Height..10... Stories .1. ...... . <br /> 4a. Absorption Field Site: <br /> Moving .......... Area .......................................... Soil Type .................................... r i <br /> o <br /> MODIIs Home ........ . Slope .......................................... <br /> PrivyPerc. Rate ................................... <br /> .......... 3. Use (describe exactly,'1 -family � <br /> Well .......... home,garage, motel,etc.) Dry Well .......... m ±� <br /> Subdivision0 <br /> Seepage Trench .......... l� <br /> T/ o i <br /> •• • )• <br /> Camping Unit .......... Priv.. . /.Y1..�. ....5 ...b.. .' y .......... <br /> . <br /> / Seepage Bed <br /> --------------------------- $_-- � — ----------------------- : 1 .� <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. 1' c <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at :ry <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. I <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> ----------------------------------- --- ------ <br /> 5. Lot Size: Fig. A. 6. LocatI91L <br /> 1.0.0.... ft. x: .K.d. ft. — sq.ft. S Gf 2 l'URO✓s{r9� l)-1 �^ <br /> 6 � s tis Kc� <br /> W <br /> ` j 0 <br /> f <br /> !'ulli <br /> rld <br /> d <br /> Ly <br /> IM .(p V W r D co co <br /> rn <br /> n — Cm n a y <br /> m > > ; <br /> rn <br /> o <br /> a <br /> ... .. .... ... . ....... ...................... ..... .�.. ../..�.(J•.� x !� m <br /> C <br /> Signatureof Ow at r gent Date 'o <br /> o . <br /> N <br /> n <br /> ........................................................................................................ ...... .................... .. ... .. <br /> S ................. 1 <br /> Inspection Date ....................................... 11 4 ... ........T1 . . ...... ...... 8 8 8 8 8 <br /> Zoning Administr t r� <br /> v <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 />