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<br /> Burnett County Office of Zoning Administrator �' o
<br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 w
<br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and
<br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of he
<br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 ro
<br /> regulations of the State of Wisconsin.
<br /> G.Y. rn..4..............C..SnI..4..r?............................... ...................................................................................... .....
<br /> OWNER lease print) CONTRACTOR or SURVEYOR or AGENT .�
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<br /> ADDRESS ADDRESS
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<br /> ADD �--. ADDRESS VI
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<br /> PH � PHONE
<br /> PLU�ERR.Q. ..'..l...J.n:s............................................... .WELL DRILLER............................................................. .....
<br /> .............................:............................................................. ...........................................
<br /> ADDRESS ADDRESS ................................................. _.
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<br /> C)........................................................................................... . ...............................—............................................ ..... o'
<br /> PHONE P..H..O..NE Z „�� r-
<br /> DESCRIPTION4. Sanitary Facilities: ° c °
<br /> 1. Work: No. Bathrooms
<br /> 2. New Building Details "' """ `Q o i
<br /> Hew Building „ ,,,,,,,, Type of Con uction: No. Bedrooms ... .... . `•
<br /> Addition ......yQ-,X,(f ,y-,d ,,, Septic Tank Size Gals. J..
<br /> .......... ...................
<br /> Sanitary ..X..... Size .............. ft. x .............. ft. ... ......
<br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: 2� Sc
<br /> MovingSoil Type ...................M....... . � c m
<br /> .......... Area ........................... ............... ... . o
<br /> Mobile Home ........ Slope ..................................I ......
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<br /> Privy ,,,,,,,,,, 3. Use (describe exactlyPerc. Rate ............................ ......
<br /> ,'1 -family 'o '
<br /> Well .......... home,garage, motel,etc.) Dry Well ... ...... m
<br /> Subdivision
<br /> Seepage Trench o :�.✓
<br /> ,,,,-,,,,, ”' �n\
<br /> Camping Unit .......... Privy ... ...... .J'•�
<br /> ...................................................
<br /> Seepage Bed ... .—
<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. `—
<br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o
<br /> CLEARLY - BEL EXISTING
<br /> STRUCTURES
<br /> -----POSED STRUCTURES
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<br /> 5. Lot Size: Fig. A. 6. Location:
<br /> ................ ft. x .............. ft. — ............................... sq.ft. ....................................................................... .......
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<br /> Sig ature o caner or Agent (��(y; Date /—/ $
<br /> Remarks ...... �_�1:.C4.... .�...l.r/.N 2/mf.....�...62...c m
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<br /> Inspection Date ....................................... MM
<br /> gAdministrator 888A
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<br /> NOTE: A preliminary site inspection must be made and sit proval granted on all structures involving sanitary fa ilities before construction
<br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this appl1 ation 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 bee issued. A permit may be
<br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or pecifications shall not be
<br /> made without approval of the Zoning Administrator. I
<br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED.
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