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Burneit County Office of Zoning Administrator �' 3 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT m <br /> M :lu <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and •� c ?0o <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 a• <br /> regulations of the State of Wisconsin. m <br /> ....W <br /> kiro..�J.e.a. m m&-w ........................................................................................ <br /> ONER IPleax print) CONTRACTOR or SURVEYOR or AGENT �.� <br /> ADDRESS ADDRESS <br /> cf!'�A.fJlllrc�.h............W............................................ . .......................................................................................... — <br /> ADDRESS ADDRESS <br /> ....................! -..8 :.1.q'..................................... ............................................................................................ <br /> PHONE PHONE <br /> .....c .c. ........Irctv/.d'y'CA................................ . . . ....... .. ........................................................................... . <br /> PLUMBER WELL DRILLER <br /> iT.. ........,1' 'e�c4......�s�..........,so <br /> ............. _ �1 <br /> ADDRESS ADDRESS » p <br /> o' <br /> ..................................... PHONE o o <br /> PHONE <br /> DESCRIPTION 4. Sanitary Facilities: 0 ^ <br /> 1. Work: 2. New Building Details No. Bathrooms •••?••• 'o <br /> No. Bedrooms AV. <br /> $ <br /> New Building ....L_ Type of Construction: Septic Tank Size Gals. <br /> Addition .......... .................................................... <br /> Sanitary /� Size ...�.�.+..... ft, x ..../0.... ft. <br /> Filling/Grading .......... Height............. Stories ............... <br /> 4a. Absorption Field Site: <br /> Soil Type .................j/QrA/./I......... o <br /> Moving Area ........................... ............... <br /> Slope ...............IT.................... <br /> Mobile Home .......... � <br /> 1 •family Perc. Rate ......................�........... <br /> Privy 3. Use (describe exactly,' Dry Well `0 <br /> Well home,garage, motel,etc.) <br /> Seepage Trench <br /> .......... Li <br /> Subdivision .......... .................................................... Privy .......... <br /> Camping Unit .......... .................................................... Seepage Bed <br /> ------------------------------------------------------------/ <br /> V <br /> C <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. :� O o <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. I J <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: +� <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... 'O <br /> � \ <br /> `I -y <br /> o <br /> � f <br /> See A"Cl). ?oma iF <br /> a <br /> T NI <br /> N <br /> Z <br /> J <br /> b <br /> N <br /> N C 'oN r O mtDM <br /> N <br /> O N `G N 0 t0 f0 <br /> D � <br /> o c m <br /> c 0 0 I� <br /> o30 <br /> O <br /> ...... ..... ....... ...................................... > <br /> C <br /> Signature of Owner or Agent Date s : <br /> T: y ' <br /> m <br /> Remarks ......................................................................................................................................................................... <br /> m <br /> o <br /> ........................................................................................................................................................................................ o : g <br /> b <br /> .......................................... ... ....... . ...................I.................... <br /> o ; <br /> Inspection Date ....................................... ....... ... ... .. u oi <br /> Zonin...Ad ministr rI� y <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities 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 been 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 APPROVED. <br />