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Burnett County Office of Zoning Administrator a M -i 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 < H o <br /> 31, <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use <br /> . .. ..... ......... 44f.. .. . . . f the State of Wisconsin. <br /> Ordinance, Sanitation Code,and with all other applicable County�Ordinances and the laws and regulation, o » a •�(� . �1 <br /> OWNER (please p t) ••��•�� � H <br /> CONTRACTOR or SURVEVO or AGENT <br /> Gfl 7/D a m <br /> ADDRESS <br /> ADDRESS .................................................... _ <br /> ............................................................................................ <br /> ADDRESS '�. <br /> PHON........................................................................................... i <br /> E . .......................................................................................... <br /> PHONE <br /> PLUMB........................................................................................... :per <br /> ER . . . ................................................................................... \\ <br /> WELL DRILLER <br /> ADDR........................................................................................... <br /> ESS ............................................................................................ <br /> ADDRESS <br /> m <br /> PH. O. .N.E.................................................................................. <br /> 0 <br /> PHONE . ....................................... 0DESCRIPTION H <br /> 4. Sanitary Facilities:1. Work: o r <br /> oo <br /> New Building 2. New Building Details No. Bathrooms v <br /> Addition Type of Construction: No. Bedrooms a <br /> .......... <br /> Septic Tank Size Gals. .......... `D <br /> Sanitary ........................... .. » <br /> .......... Size .............. ft. x .............. ft. <br /> Filling/Grading .......... <br /> Height............. Stories ............... 4a. Absorption Field Site: i <br /> Moving .......... Area ni <br /> ........................................... Soil Type .................................... o: <br /> Mobile Home Slope ?' o <br /> Is Privy .......................................... „ . <br /> 3. Use (describe exactly, 1 -family F <br /> Perc. Rate ................................... r <br /> Well home,garage, motel, etc.) Dry Well <br /> Subdivision �/ ••........ ; <br /> .......... ................................... Seepage Trench <br /> Camping Unit ................. <br /> .......... Privy ik <br /> .................................................... .......... y n <br /> ------------------------____ Seepage Bed c <br /> Location proposed structures and existing structures, well, sewage sould be sketched in Fig. A. Include road C c <br /> setback, side <br /> Ystems, roads etc.,should e and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- n <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING k, C <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS, 4 H <br /> ------------------ <br /> ----------------------- <br /> 5. Lot Size: ----------------------- <br /> o ` <br /> Fig. A. 6. Location: ° ' $ <br /> ................ ft. x .............. ft. — w <br /> ...................... sq. ft. .......................................................................: r, W i <br /> L ti <br /> r <br /> p r� <br /> i � a <br /> I r <br /> O <br /> 1 � <br /> 7J <br /> on r OIZ <br /> A , m .Nc N <br /> n c < — F <br /> LD. 2- <br /> — <br /> o < � mmv <br /> Z o. y a m <br /> Ut <br /> / o -i <br /> C) <br /> ............................................................. �6 pl <br /> M <br /> Signature of Owner or Agent """ . ' ' <br /> Date g t C <br /> Remarks ......................................................................................................................................................................... X — <br /> m m <br /> ........................................................................ <br /> v <br /> ................................................................. o <br /> ......... ..._.............. ................. . . . . . <br /> Inspection Date ....................................... o�i <br /> O N O <br /> Zoning Ad inktrator �J 8 8 8 8 8 8 y <br /> VOTE: A preliminary site inspection must be made and site approval granted on all structures involving sai itary facilities <br /> tefore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> his application before a permit will be issued. Do riot purchase or install a septic tank, do any plumbing or start any build <br /> - <br /> ng until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here <br /> - <br /> vith 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 />