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Burnett County Office of Zoning Administratoro/ o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <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 m C <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. a <br /> 3 O <br /> al1. ..... . ...... .... ..1.. ........................................ ....................5�................... N F <br /> O ER (pleacse print) CONTRACTOR or SURVEYOR or AGENT o. _ <br /> .......�.6........................... ............................................................................................ 1- <br /> ADDRESS ADDRESS <br /> ADDRESS �/ .2n ............................ ADDRESS 1 <br /> ..............................9 V...................................................... . <br /> .......................................................................................... <br /> PHONE .� <br /> PHONE 1n <br /> ........................................................................................... v` <br /> PLUMBER . .......................................................................................... <br /> WELL DRILLER <br /> ........................................................................................... <br /> ADDRESS .A.......................................................................................... O <br /> DDRESS <br /> n p G <br /> PHONE ....... . ....... . ............ 0. . ................................... .......................... PO ........................ ......... <br /> DESCRIPTION 4. Sanitary Facilities: o 0 <br /> 1. Work: 2. New Building Details No. Bathrooms .......... o <br /> New Building .. T No. Bedrooms 'C <br /> ype Construction: • <br /> m <br /> Addition ......•••• , , .....Lc- •••,,,,•,. Septic Tank Size Gals. .......... <br /> . ..... ....... ..... <br /> Sanitary .......... Size ..ice.{.�..... ft x �— <br /> ! ... .......... ft. .......... <br /> Filling/Grading .......... Height St St ries ............... 4a. Absorption Field Site: <br /> Moving .......... Area ......... x'..75 . Soil TYPe .................................... qj.� •r i <br /> ... ................... <br /> o <br /> Mobile Home ........ . Slope .......................... ............... .. <br /> Privy .......... 3. Use Idescribe exactly, 1 -family Pend. Rate ................................... <br /> Well .......... homg,/g'a�ra�ge, motel, etc.) Dr Well <br /> C v .......... <br /> Subdivision ...,,,,,,, Z FJ�'f`aCr Seepage Trench <br /> g .......... <br /> Camping UnitPrivy ......,.,, f <br /> .......... <br /> ----------------------- Seepage Bed <br /> Location of proposed structures and existing structures well, sewage systems, roads etc., should be sketched in Fig A. Include road t : an <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 /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> W :p o <br /> 5. Lot Size: r Fig. A. 6. Location: <br /> /' <br /> .`.U. ..... ft. x �.�... ft. — .. /.�'..vv............ sq.ft. ............................................................................... :�- <br /> iC <br /> s <br /> C O <br /> U o <br /> N . <br /> 0 <br /> 4�z „ -c <br /> a <br /> z Z <br /> y <br /> 1 _ v�- <br /> �lCyv ' U <br /> F <br /> 3 N r 9 N W Z <br /> n zr < c m <br /> m N d 6 m n W <br /> C <br /> Z oo' � nam <br /> a � z <br /> o �n am 3 <br /> of <br /> q m <br /> m <br /> Watu, <br /> .. G l 5 �' OSiOwner of Agent Date �» C <br /> 0 <br /> X M <br /> Remarks ............................ In m <br /> I O <br /> .....................................................-....................................................................................................................... <br /> ........................................................................................................... .... ...................... . ........................................... <br /> Inspection Date . . . ... "�.".................. E o : U 'o N m <br /> ...................................... ..... . .... ........ .... ..... <br /> m <br /> Zoning A inistrator $ $ $ $ � y <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilIt es <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 be made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />