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Burnett Countf Office of Zoning Administrator v -- 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT �' 3 <br /> O <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as H <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m � <br /> Ordinance, Sanitation Code,and with all other applicable County Ord es and the laws and regulations of the State of Wisconsin. n <br /> .... y................................. � . .. ............................. N ° <br /> a <br /> OWNER (please print) CO RA OR or SURVEYOR or AGENT n. <br /> ............................................................................ �� i... a ............................................. d <br /> ADDRESS AD FSS <br /> . ,e .. Gil...... S.Y.. .7 ........................... <br /> ADDRESS ADDRESS 1� <br /> ........................................................................................... ............................................................................................ .� .. <br /> PHONE ........................................................ PHONE <br /> ................................... ............................................................................................ Q?1 <br /> PLUMBER WELL DRILLERxx <br /> ADDRESS ADDRESS n o <br /> o........................................................................................... ............................................................................................ .i <br /> PHONE PHONE Zr" <br /> DESCRIPTION 4. Sanitary Facilities: o o 0 <br /> D <br /> 1. Work: 2. New Building No. Bathrooms "" <br /> Details " o E <br /> New Building .......... Type of Construction: No. Bedrooms .......... <br /> Addition .................................................... Septic Tank Size Gals. .......... <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... <br /> Fining/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... <br /> Mobile Home .......... Slope .......................................... .. n <br /> Privy .......... 3. Use (describe exactly, 1 -family Pere. Rate ................................... <br /> Well .......... home,garage, motel, etc.) Dry Well .......... <br /> Subdivision .......... Seepage Trench .......... <br /> Camping Unit . .. .................................................... Privy .......... <br /> Seepage Bed .......... <br /> -------------------- .N <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 �- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING G <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — sq. ft. <br /> A <br /> 1 N j" o <br /> �7d X71 <br /> 1 0 <br /> t � o <br /> 0 <br /> - lry O <br /> 7J <br /> a <br /> � m <br /> c <br /> r M :E n m z <br /> c a <br /> m N d C y B m <br /> Z oo' > M <br /> o n m 3 <br /> fA <br /> � f 0 <br /> :9J o 70 <br /> 67 m <br /> cv ET <br /> o c <br /> Signature of Owner or Agent Date <br /> X 77 <br /> Remarks ............................................................. m <br /> ......................................................................................................... ......................... . ......... : T <br /> ) N i <br /> Inspection Date ....................................... . ....... ...7+�... : \�; e o u o 0 o u m <br /> Zoning dministrator ° 8 $ 8 8 8 8 CA <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 riot 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 />