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Burnett County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT 3• 3� <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and :a <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 County Ordinances and the laws and 3 `d <br /> regulatio softhe State of Wisconsin. n <br /> .... .. .. ...... .................................................... ...... n <br /> `... .. .. ... .. .. . <br /> OWNER IDlaese print a �„ CONTRACTOR SURVEYOR or AGENT <br /> 1 .+ .1...... .i.9.........` .. s< , •. ...... . . ............................................................................... — <br /> c� <br /> ADD ESS ADDRESS � I <br /> . . ................................................................................ . ...... . .RES............................................................................... :Q <br /> ADDRESS ADDS t <br /> .... ..................................................................................... . ................... <br /> ....................... <br /> ................................. ....... <br /> PHO..NE PHON........E <br /> ........................................................................................... . . . . . . .............................................................. ....... <br /> PLUMBER WELL DRILLER <br /> O <br /> ADDRESS ADDRESS 'm 0Cl <br /> n O <br /> ........................................................................................... ..... . .......................................................................... ....... O »' <br /> PHONE PHONE.. .. ZN r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: j�. New Building Details No. Bathrooms ` o <br /> New Building Type of nstru ion: No. Bedrooms .. ....... 'f <br /> Addition „ ,,•,•,d' i, / Septic Tank Size Gals. .. ....... » <br /> .......... ........ <br /> Sanitary Size ..... .... ft. x ....�..�... ft. .. ....... <br /> Filling/Grading .......... Height...... ..... Stories1l. . .......... 4a. Absorption Field Site: E� <br /> Moving Area ......I ��^^..,, t"Y.,v...... Soil Type ............................ ....... ° <br /> Mobile Home .......... �rJ... Slope .............................I.... .... <br /> ... » <br /> ..... .... <br /> Privy ....•..... Use (describe exactly,'1 -family Perc. Rate ........................... ....... <br /> m <br /> Well ........., home, a age, mm�ot�el�,petc.) Dry Well .. ....... <br /> Subdivision ,.,,,,,,,, z <br /> Y�Q9�” '"� _ Seepage Trench . <br /> .. ....... o i <br /> ..... ...... . ......... .. ....... ....... ...... } <br /> Privy .......Cemping Unit ,,,,...... .................................................... <br /> Seepage Bed <br /> Location of proposed structures and existing structures well sewage systems, roads, etc., should be sketched in Fi A <br /> . <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is local d at ,YJ <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 /> ________------ _________________ __ <br /> 5. Lot Size: Fig. A. 6. Location: i✓ E <br /> ................ ft. x .............. ft. — ............................... sq.ft. ...............................................................................a IN <br /> ,1 _ - <br /> I v :5-s <br /> n n I <br /> O <br /> — W <br /> V ( e <br /> co r- D to W <br /> m n•< - nm nn 9 <br /> vo< � Cy > > 3 <br /> Z ovi_ N pro m <br /> D � —f <br /> of _mil , m <br /> m <br /> o <br /> e '.... ....... .. .. la./ �. � x A <br /> ........... ........... ............. A . m <br /> Signature of Own or Agent Date c <br /> Remarks M N <br /> m <br /> u <br /> . . ...... . . ..2.I. /// . . . ... .. e <br /> N 8Gl .N <br /> NmInspection Date ....................................... vm <br /> Zoning <br /> on <br /> NOTE: A preliminary site inspection must be made and site approval 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 appl 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 bee issued. A permit maybe <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, <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND API ROVED. <br />