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<br /> Burnett County Office of Zoning Administrator �' o
<br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 W
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<br /> 70 THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described iind +
<br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m c
<br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws nd 3 q `C
<br /> regulations of the State of Wisconsin. /? :q g
<br /> NER (please print) CONTR CTOR or SURVEYOR o cA®GENT
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<br /> ADDRESS ADDRESS ^�
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<br /> PH E �Iy PHONE •• 1
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<br /> PLUFA E WELL DRILLER
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<br /> DESCRIPTION 4. Sanitary Facilities: ` P0
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<br /> 1. Work: 2. New Building Details No. Bathrooms ...... ...
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<br /> �� No. Bedrooms ... .d
<br /> New Building ,,,,,,,,, Type of Construction:
<br /> Addition F—h• 4.-{ , ,,,,,,,,,, Septic Tank Size Gals. .. .......
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<br /> Sanitary „y, . Size ....A.Q.... ft. x ....a g ft. •S�
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<br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site:
<br /> Moving .......... Area ...................................... Soil Type ............................ ....... r i
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<br /> Mobile HomeSlope .................................. ....... ..
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<br /> Privy ......•... 3. Use (describe exactly,'1 Tamil Perc. Rate ........................... .......
<br /> Well ,,,,,,.... home,garage, mot I,etc. Dry Well m I
<br /> . II (R�'� Seepage Trench Z
<br /> Subdivision .......... ...�..l..�M.t(.:�...�.t.!.LXf.IV....... .. .......
<br /> Camping UnitPrivy
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<br /> Seepage Bed
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<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 local Bd at
<br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersec ion. �� ` 5.
<br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. �..� 0
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<br /> 5. Lot Size: Fig. A. 6. Location: fn'•, m
<br /> ................ ft. x .............. ft. — ............................... sq.ft. .... ....... .�.i ll.h�.t .R
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<br /> Signa4 re or Agent Date $
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<br /> Remarks
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<br /> Inspection Date ....................................... ... .. .. ..../.;,...9 . p...... a , v, o o �n m
<br /> Zonin Adminis for �8 8 8 8 8 Sin
<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 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 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 AP ROVED.
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