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(7y I11� is <br /> Burnett County Office of Zoning Administrator 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT a 3. o J <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as .n µ <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 /> and the laws and regulations of the State of Wisconsin. 3 I <br /> Ordinance, Sanitation Code and with all other applicable County Ordinances `\ <br /> / � . r H d <br /> ................................ jL..... >;..Y..J................................ <br /> ............ p <br /> OWNER (please print) .•••.•..•• CONTRACTOP or SURVEYOR or AGENT a � m <br /> ............................... ................................................................ ........................... . <br /> ADDRESS ADDRESS = i <br /> ........................................................................................... . ..........S,4S—................................................................. <br /> .......... pn <br /> J <br /> ADDRESS ADDRESS ti <br /> ........................................................................................... ............................................................................................ <br /> PHONE PHONE � <br /> ........................................................................................... . . . ..................................................................................... <br /> PLUMBER WELL DRILLER <br /> ........................................................................................... ............................................................................................ p <br /> ADDRESS ADDRESS m <br /> 0 o <br /> ........................................................................................... . . .................................................................................. o' <br /> PHONE PHONE...... .. Z H r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathroomso <br /> .......... <br /> New Building .......... Type of Construction: No. Bedrooms .......... `• <br /> Addition .................................................... Septic Tank Size Gals. .......... <br /> Sanitary ..... ,,,, Size .............. ft. x ft. .......... <br /> Filling/Grading ......,,,, Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Area Soil Type ..........4......................... r i <br /> Mobile Home .......... Slope .......................................... o.. <br /> Pere. Rate ................................... <br /> Privy .....,,,,, 3. Use (describe exactly, 1 -family <br /> Well ,,.....,., home,garage, motel, etc.) Dry Well :v <br /> Subdivisionv Seepage Trench .......... <br /> i <br /> .......... ..................................4................. <br /> Camping Unit .......... .................................................... Privy .......... <br /> Seepage Bed .......... <br /> -------------------------- <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc., should be sketched in Fig. A. Include road <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter O- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> 0 <br /> R UCTU RES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> _ ------------------------------------------------------------ : <br /> . Lot Size: Fig. A. 6. Location: <br /> ................ ft. x ........../... ft. — .......C.)........./.................... sq.ft. ............................................................................... <br /> � i I N o' <br /> ISD <br /> r. O <br /> I 4 <br /> 0 <br /> r v w W Z <br /> m c c m <br /> f <br /> \ j <br /> on <br /> Z O O' . D a m <br /> F» — <br /> o � <br /> Jv m <br /> ..atu...re......of...O...w....ner......or...A..ge.................................... .6..y .:.D��ate ............. €v s c <br /> Signnt :�I * <br /> X Z7 <br /> Remarks ......................................................................................................................................................................... m :`C 0 <br /> .......................................................................................................... <br /> ......................................................................................................... :a <br /> r <br /> ' T <br /> .............. .../../...................................................... <br /> Inspection Date .................4.4............44..... a2Z?�Cf..1..`. ... J.............. �8 8 8 8 8 8 8 M <br /> :1 <br /> Zoning Admi istratorcn <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 be made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />