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Burrett County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT a <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and p <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the c <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable Count Ordinances and the laws and <br /> PP Y 3, <br /> regul ons of the S ate of isconsin. m <br /> .... <br /> �T��.c. ...... i� ........... - <br /> OWNER Ipleese print) CONTRACTOR or SURVEYOR or AGENT _ <br /> /lv.a..l....... ��. ...laJa.a ... .r !......... ............................................................................................ d - <br /> 4 <br /> ADDRESS ADDRESS m- <br /> ...... .................................................................................... <br /> ...................N."... T � . <br /> ADDRESS ADDRESS <br /> �f� s. .......GU........... °!......... ............................................................................................ :R <br /> PHONE PHONE ; <br /> 3(F............................................................... . .......................................................................................... <br /> WELL DRILLER <br /> PLUMBER ' <br /> O n) <br /> ..... . . . ............................................................................... . .......................................................................................... m Ll � <br /> ADDRESS ADDRESS M ° <br /> _ c <br /> ................................................... . .......................................................................................... r <br /> . ................... PHONE <br /> PHONE 0 <br /> .. ................ . <br /> 4. Sanitary Facilities: ° °^ <br /> DESCRIPTION ; <br /> 1. Work: 2. New Building Details No. Bathrooms E 0 <br /> No. Bedrooms .......... i <br /> New Building .......... Type of Construction: 3 <br /> Septic Tank Size Gals. .......... <br /> Addition .......... .................................................... <br /> Sanitary .......... Size .............. ft. x .............. ft. <br /> ......... <br /> Filling/Grading Height............. Stories ............... 4a. Absorption Field Site: <br /> .......... ' <br /> Moving Area Soil Type .................................... o <br /> Slope .......................................... <br /> MODIIe Home <br /> 3. Use (describe exactly, 1 -family Perc. Rate ...................................Privy <br /> ((� <br /> Well Dry Well <br /> Well home,garage, motel,etc.) Z l <br /> Subdivision .......... .................................................... Seepage Trench . . ° 0' <br /> --Camping Unit_ Privy ...�. !J-> <br /> Seepage Bed .......— <br /> ---------------- <br /> ��. <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 CJ �. <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. o <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. t <br /> :k ° AP <br /> -------------------------------------------------------- <br /> 5. Lot SiFig. A. 6. Location: <br /> 7., .. N.... ft. x .. .` ft. . ............. ......... sq.ft. ............................................................................... � <br /> UC r� I <br /> / o <br /> o i - - <br /> 1 0 <br /> ;7 _ <br /> T 5 <br /> : ( m <br /> 9 1 : Z <br /> x/ O <br /> a <br /> 7 <br /> b <br /> m <br /> AW V N n 03 03 <br /> 0 N Q O. <br /> QG d co J 5 ; <br /> ON ur OO m <br /> Z-0 m D 1 <br /> O O N n : y <br /> c 0In <br /> ..... 9�nSqkt45Z.. . ................ <br /> Signature o -iDate <br /> Remarks ......... . .......... ..... ............................. . .. ........ ..... . w <br /> m <br /> N <br /> a N <br /> ... <br /> ... ... <br /> o <br /> ................................... <br /> � 8� N m <br /> om <br /> Zonin � mor AInspection Date ....................................... gA �/ : N c <br /> nist <br /> NOTE: A preliminary site inspection must be made and site approval 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 application 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 been 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 />