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Burnett County Office of Zoning Administrg for <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT3 <br /> o <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 the m g$ (r7 <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the State of Wisconsin. g <br /> ............................ .......of e................................................................ ...... A j <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT $ <br /> . ?.}'... ................................................................. ..................................................................................... ...... <br /> ADDRESS ADDRESS <br /> /�i: /... . ../12.! ....so37....................... .............. . <br /> ADDRESS J ADDRESS..................................................................... ...... �� :, <br /> <. -...7.. /.......................................... ..... . . . <br /> PHONE PHONE <br /> ................. <br /> PLUMBER 14�in........................................... .WE.....L..L...DRILLER........................................................ . <br /> i <br /> 1P�3..... .. . . ,o <br /> AD RESS ADDRESS <br /> 9 p <br /> ............................................ .................................................................................... ....... o 'hJ <br /> PHONE PHONE Z ,n r <br /> DESCRIPTION 4. Sanitary Facilities: P o <br /> t. Work: ng Details No. Bathrooms i� 0 <br /> ,/ No. Bedrooms ....... <br /> New Building ,,,,,,,,,, Type of r cti n: `•^ <br /> Addition ..... , „ , Septic Tank Size Gals. <br /> New <br /> Filling/Grading Height....... .... .tori. . <br /> .......... . . . �f <br /> Sanitary i Size .. ft. x ..C?... ... ft. •• ••••••• ; <br /> ' .... Stories ............... 4a. Absorption Field Site: �} <br /> Moving .......... Area Soil Type ............................ ....... <br /> eMobile HomeSlop .................................. ....... �+ <br /> Privy .......... 3. Use (describe exactly,"1 •family Perc. Rate ........................... ....... o <br /> Dry Well .. ....... � <br /> Well ........., home,garage, motel, tC.l Seepage Trench o J <br /> Subdivision .......... .....I... .. . . 1.... ... . f�— <br /> " Privy } <br /> Camping Unit .......... ...............�.. .... � <br /> Seepage Bed .. ....... :;I' `�. <br /> Ln <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fill. A. <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is Iota d at )t <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersec ion. ;;.ji ` <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> ___________________________________________________________________ __ <br /> 5. Lot Size: Fig. A. 6. Location: i <br /> ................ ft. x .............. ft. . ............................... sq.ft. ...................................................................... ........ <br /> 0 O <br /> Qj <br /> Z � <br /> 0 <br /> 9 <br /> a <br /> e <br /> m <br /> m c m m 0c <br /> a < o 0 m M 9 <br /> 0 r^ 0 - - rn <br /> , <br /> Z 0 <br /> O D —1 <br /> � N7 N4 A <br /> O c m <br /> = 0 : 0 <br /> C <br /> A : m <br /> ........................................................................... ...................................... > O <br /> Signature of Owner or Agent Date S <br /> Remarks �I �. r...�. �:C...r� m <br /> :.... ... . . ............................................................................................................................ ..... <.. <br /> w <br /> o : o <br /> r� " M <br /> ............. <br /> .. ................................. <br /> a 0, <br /> InspectionDate . .�.1.....�................. ....... ............................. .............. . N o o T <br /> Zoning Administrator S S S S S S to <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary f ilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this app ication 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 i 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 />