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Burnett County ,. Office of Zoning Administrator V R <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT3 <br /> a. <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 n tt O <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 ib <br /> regulations of the State of Wisconsi -. <br /> ! .'�.L. 5....... ..4.�.............. .......................... . .......................................................................................... <br /> OWNER (plea print) CONTRACTOR or SURVEYOR or AGENT _ <br /> .. ...I.....r.................t.�.f �• <br /> a <br /> ADD ESS ADDRESS 01 <br /> r ...� s Coda....13. <br /> APYRESS .................. <br /> ADDRESS <br /> ............... ............................................................................................ <br /> PHONE PHONE (r <br /> J/(fes. ..... ............................................... . .......................................................................................... i IGO <br /> PLUMBE WELL DRILLER •-i� :� <br /> ........................................................................................... <br /> ADDRESS ............................................................................................ <br /> ADDRESS n o <br /> ........................................................................................... 0 < - <br /> PHONE <br /> DESCRIPTION 4. Sanitary Facilities: ° o 0 <br /> 1. Work: 2. New Building Details No. Bathrooms •a <br /> New Building No. Bedrooms .�— ° ' <br /> Type of Const[ on, •••• •• $ <br /> Addition ..-,•,••.• ......_... c. /c l�er�' Septic Tank Size Gals. <br /> Sanitary .. ... Size .............. ft. xv... ...... . .ft. .......... <br /> 0.............. <br /> Pilling/Grading ,,,,,,,,,, Height............. Stories ............... 4a. Absorption Field Site: i <br /> Moving .......... Area ......................I............I....... Soil Type .................................... r- i <br /> Mobile Home Slope ° <br /> .......... p .......................................... r .. <br /> Privy ,,,,,...., 3. Use (describe exactly, 1 -family Perc. Rate ................................... - <br /> n <br /> Well ..,--..,,, home,garage, motel,etc.) Dry Well .......... 0 <br /> Z <br /> Subdivision Seepage Trench .......... ° <br /> CampingUnit .......... ................................I................... Privy <br /> Seepage Bed <br /> ---------------------------------------------- L 4- <br /> n <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. c <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at � g <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. <br /> 0 <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ft. x .............. ft. - ............................... sq. ft. i� <br /> ............................................................................... .� <br /> n <br /> N <br /> f� <br /> O <br /> 1 <br /> 0 <br /> a <br /> T <br /> Z :2 <br /> O <br /> (n l7 m r- D W m -0 <br /> v ,nom <br /> O-. . N C0 7 7 3 <br /> OTno � .`D .� D� 1 <br /> . n : y <br /> o = m <br /> D <br /> S <br /> ... .. ...... ...... ...................... ......................... a <br /> Sign Remarkstura ............ <br /> of ner or Agent Date o : O <br /> o . <br /> o <br /> .......................................................................................................................... m �. � � a � . <br /> m •• <br /> �. <br /> O : o <br /> I . o <br /> ................................................................................................................................ o ' <br /> Inspection Date ....................................... .... ..... ... v, o o m <br /> J � m <br /> Zoning Admini rator l $ o o g Ul <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 /> nade without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />