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Burnett County Office of Zoning Administrator <br /> APPLIICAT10N 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 nd <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the r$ a <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws nd <br /> reguliAliens of the St teof Wisconsi n. w <br /> ..: .. ... ?. rf�� r........................... . = i <br /> ............................. <br /> ... .... . .. <br /> OW ER (plem print) CONTRACT R or SU VEVOR or AGENT <br /> ....1.!k......1.0...................................................................... .... .f.'....�.....l..I�..... ...M............................... ...... <br /> D ESS AD ESS <br /> AD <br /> ��� �.).. ! ...=??1 <br /> ................................ ........................ ...... <br /> ADDRESS ADDRESS <br /> . . ...................................... <br /> PHONE ........................................... ...... <br /> PHONE................................................................................ <br /> PLUMBER............................................................................ .WELL DRILLS..R......................................................... ... .^^�'' <br /> ALJ <br /> ADDRESS ADDRESS C <br /> .......................................... ...... O w <br /> ........................................................................................... .......................................... . <br /> PHONE PHONE Z N r 0_ <br /> DESCRIPTION 4. Sanitary Facilities: P ° <br /> No. Bathrooms '-� <br /> 1. Work: 2. New BuildingDetails """"' c <br /> New Building No. Bedrooms <br /> ,,,,,,,,,, Type of Construction: "' ""-' <br /> Addition .................................................... Septic Tank Size Gals. .......... i <br /> ......... J <br /> Sanitary Size .............. ft. x .............. ft. .......... <br /> Filling/Grading ...I...... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... Soil Type ............................ ....... o i <br /> Mobile Home .......... Slope .................................. ....... .. <br /> Privy .•...•.... 3. Use (describe exactly,'1 -family Perc. Rate ........................... ....... E <br /> n <br /> Well . Dry Well, , home,garage,motel, etc.) " """' <br /> Subdivision Seepage Trench o <br /> " """' ' <br /> Privy <br /> Camping Unit <br /> Seepage Bed <br /> Location of proposed structures and existing structures well sewage systems, roads, etc., should be sketched in Fi . A. <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is locat d at <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. 131) i o g�a' <br /> __________________________________ _______--_______________________ _ J ii x� <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq. ft. ............................................................................. <br /> �C_ � 0 <br /> J ~ <br /> N <br /> aJ <br /> � r � <br /> 0 <br /> J <br /> _ Z <br /> V� ° <br /> mss p <br /> 0 � diu > mm -0 <br /> p - -. m <br /> "o., a a EL L <br /> � CNjJJ3 <br /> Z O NG p O m <br /> o 2 a <br /> P N N n <br /> o c m <br /> ° : 0 <br /> Vs , <br /> c <br /> nm <br /> .................................................................... ...................................... > G <br /> ignature of Owner or Agent Date : g <br /> N <br /> Remarks m a <br /> o : g <br /> ........................................................................................................ ........................) . �. ...... ... .. .. t <br /> Nv, Drn7 Nrn +o O Nrn <br /> 'n <br /> Inspection <br /> Ins ection Date N . . ..... <br /> Zoning Administrato <br /> g g g o 0 o W <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary fa ilities 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 bee i 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 AP ROVED. <br />