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6TY1 G"YI1,r�} , <br /> Burnett County Office of Zoning Administrator a m - Z <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use (V^\ <br /> Ordinance, Sanitation,Code, <br /> and with all other applicable County Ordinances and the <br /> laws and regulations of the State of Wisconsin. 3 a i V C <br /> .�"QJ !'' '1f!!LICLL.............................................. 1..:./.. ..�.^` "..... j......"/../.J. vY!!UXt................................ m Q O <br /> O NER (please print) CONTRACTOR SU RVEYVH or AGENT m <br /> .................................. � ... 1 au< ....................................................... <br /> SS <br /> AD............................ ��.. 5 ....................... <br /> ADDRESS ADDRESS �O <br /> ........................................................................................... ............................................................................................ <br /> PHONE..... . . . . . . . . . . .. . .......... PHONE <br /> ...... . ..........IfR ........................................................................... <br /> ... . ... .... . ..... ....... ....... ... ...... ........ .... . RI <br /> .LLER <br /> PLUMBER WELL DRIi <br /> ADDRESS ADDRESS m 0 <br /> ........................................................................................... ... ..................................................................................... o' rF <br /> PHONE PHON.... E Z H <br /> DESCRIPTIONr <br /> 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms o <br /> New Building ,,,,,,,,,, Type of Construction: No. Bedrooms .......... <br /> Addition .................................................... Septic Tank Size Gals. .......... <br /> .......... <br /> Sanitary Size ft. x ft. .......... <br /> Filiingl Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area Soil Type .................................... r <br /> ........................................... o <br /> Mobile Home .......... Slope .......................................... <br /> Privy3. Use (describe exactly 1 -Tamil y Pere. Rate ................................... i <br /> .......... <br /> Well .......... home,garage, motel, etc.) Dry Well .......... <br /> Subdivision ,t/ Seepage Trench .......... <br /> .................................................... <br /> Camping Unit .......... Privy .......... <br /> .................................................... <br /> Seepage Bed .......... <br /> ------------------------- ---------- N <br /> Location of proposed structures and existing structures,well, sewage systems, roads,etc-, should be sketched in Fig_ A. Include road Q <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property Is located at a highway inter- _- <br /> section, show the intersecting highways and the setbacks required along them and at the Intersection_ CLEARLY LABEL EXISTING = <br /> 0 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. r p' <br /> -------------------------------------------------- ------------------ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq. ft. ............................................................................... <br /> J <br /> I N O <br /> r <br /> s <br /> c � o <br /> a <br /> _ <br /> r no d 0 Z <br /> 0 <A F <br /> -O cl <br /> m <br /> p H D a m <br /> Z O o ¢ 77 <br /> o = ¢m 3 <br /> ;kj D M <br /> o?9-�S� s c <br /> .g"n'a' .................................................................. ..................a................... <br /> Signature of Owner or Agent Date <br /> X <br /> Remarks ......................................................................................................................................................................... m <br /> In <br /> O <br /> m <br /> e» ' <br /> W II <br /> .......................................................................................................... . ....................,.y...9............................................. to <br /> Inspection Date ....................................... Q'/?.2 ....l....... ...................... i �'��y}}VJJJ ti ry °° ^' m <br /> Zonin Ad or a� E Ig 8 8 8 8 8 8 c) <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> this application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build <br /> Ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here <br /> with is found to exist. Changes in plans or specifications shall not tie made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />