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Burnett County Office of Zoning Administrator d o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. <br /> 0 <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 <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> Z ,� ✓/LO' 20 s a <br /> .1.`�.�......f..... ....../.. ... ` ........ ............ .........................�;........... ................................ - o <br /> O/,W� NER (please print �... .......� CONTRACTOR or SURVEYOR or AGENT a <br /> " ADVfl ADDRESS <br /> ' :.....fir ... .......moi....svoay............ ............................................................................................ <br /> ADDRESS ADDRESS <br /> ........................................................................................... . . . . .................................................................................... <br /> PHONE PHONE <br /> i� <br /> ........................................................................................... . . DRI. .LLE. . ..R.................................................................... <br /> PLUMBER WELL <br /> ADDRESS ADDRESS m 0 <br /> :r o <br /> a <br /> ........................................................................................... . ......................................................................................... O <br /> PHONE P..HONE Z N <br /> r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms o ' <br /> New Building Type of Construction: No. Bedrooms .......... 'o <br /> Addition .................................................... Septic Tank Size Gals. .......... i < <br /> .......... <br /> Sanitary .......... Size .............. ft. x ft. ••.••... <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... Soil Type .................................... rO <br /> MobileHome Slope .......................................... o .* <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Well .......... home,garage, motel, etc.) Dry Well .......... <br /> o <br /> Subdivision ✓-,,, Seepage Trench .......... <br /> .................................................... A <br /> Camping Unit .......... Privy .......... tt <br /> .................................................... Seepage Beds' <br /> .......... <br /> ______________________________________________________________________ r' i <br /> Location of proposed structures and existing structures,well, sewage systems, roads,etc., should be sketched in Fig. A. Include road l � <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 c <br /> H <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o o <br /> ---------------------------------------------------------- ------- --- i <br /> 5. Lot Size: Fig. A. 6. Location: <br /> o C E <br /> ................ ft. x .............. ft. — ............................... sq.ft. p <br /> ». <br /> N O <br /> wl /,I Y, SS :{Sin 1.. ..-- _ so CC4 <br /> _ 0 <br /> Vill <br /> v . <br /> • ii ;i � �� m � :r <br /> ii <br /> 0 <br /> I <br /> x <br /> N r 9 e to Z <br /> m �a < <br /> < m c M <br /> - m <br /> Z <br /> • -m 3 <br /> �o <br /> `J // �o m <br /> ........................................................................... ......................................� :W� <br /> Signature of Owner or Agent Date ° — <br /> X M <br /> Remarks ......................................................................................................................................................................... .o m <br /> M <br /> en <br /> ........................................................................................................................................................................................ �p <br /> ...................................................................................................... ... ..................... :� . <br /> w T <br /> N N + m + N m <br /> InspectionDate ....................................... �.. ....:......... .... ...m.. ...............✓............... <br /> ZoningAd 'nistrator K 8 8 8 8 8 8 (n <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 huild- <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 tie made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />