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Burnett County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT gg 1 3� <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 t <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws rad 3 `d <br /> regulations of the State of Wiscopsi n. � g r <br /> J — » ✓� <br /> ..........t3R�21)... . � alt............................................ .......... tl�?....� AA.on- .��:� 4� ........... ..... A <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT <br /> .................. ................... <br /> ADDRESS ADDRESS <br /> n rC'HIC z(7......� �.:...` .` z�7....... .......... . . . E <br /> ..................................................................... ...... <br /> ADDRESS ADDRESS <br /> ............... ...... ............................... . . . ............................................................................... ...... <br /> PHONE r PHONE (0 <br /> ...............I .!.��. ':'... .'`.D. .:L-::.:1... ................................. ..................................................................................... ...... 4 <br /> PLUMBER WELL DRILLER . <br /> � T 3 PJLS 9 ....,...1....../.' <br /> ADDRESS ADDRESS i m L'I <br /> ....A .0. o <br /> ...:...................... ..................................................................................... ...... 'o' n) <br /> PHONE PHONE 9 0 <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms I v <br /> 2. New Building Details "' <br /> New Building k Type of Construction: No. Bedrooms ... . — '•i q <br /> Addition Septic Tank Size Gals. <br /> .......... C. F..C� ' <br /> pQ <br /> Sanitary .... . . Size ..,'. �?... it. x ....✓'... ..... ft. <br /> Filling/Grading ,..,.,.... Height....... .:... Stories ....�.f... tion Field Site: <br /> ...... 4a. Absorption i <br /> Moving .......... Area .............9 Soil Type .....................SAC <br /> Mobile Home .......... Slope .............................�.. . <br /> Privy .......... 3. Use (describe exactly,fl -family, Perc. Rate ................... 2 � <br /> Well .......... hoe,/garage,garage, motel, etc.) Dry Well .... �, •;� <br /> .. .. <br /> Seepage Trench • z� <br /> Subdivision .......... ................................... ................ ... ...... <br /> Camping Unit .......... Privy <br /> .................................................... //r ... ...r.. a . <br /> Seepage Bed <br /> --------------------------------------------------------------- -- <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 intersect on. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. - � 0 <br /> 5. Lot Size: .-� Fig. A. 6. Location: :CT <br /> ....�.. ft. x .."(.Q C. ft. — .� �. .��..... sq.ft. �.�-.'... .........` C!Q1 .(T.... .f <br /> './ N ��;�1�rt.•� 0 <br /> 0 <br /> o <br /> N <br /> z <br /> o : <br /> .f% M m -0 (n r D co ID y <br /> N c _. W N N c c <br /> 0 rBcr 0 _ m <br /> a <br /> T. nm nny <br /> S N < ND rp ep <br /> 7 N n 9 <br /> o <br /> t' firs <br /> Q.. ........ ......... . . ...� ............ . ./.. . . ...... . p <br /> Signatu-e of Owner or gent t Date : 8 <br /> Remarks ......C! :.�r.... .: ....... ................................................................................................................................ .... m <br /> o . c <br /> 0 0 <br /> ............................................................................................................. .... .................. ................................... .... o . <br /> 7 Inspection Date A� ,ZN <br /> ............. <br /> m <br /> Zoning ministrator <br /> NOTE: A preliminary site inspection must be made and site roval 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 app)cation 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 beeit issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or 3pecifications 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 />