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<br /> Burnett County Office of Zoning Administrator e M o
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<br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT a _ r�s
<br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as
<br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use
<br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin.
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<br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT a
<br /> ..... ....................... .ADDRESS............................................................................
<br /> ADDRESS m
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<br /> ADDRESS
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<br /> PHONE PHONE '^6
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<br /> PLUMBER . ..........................................................................................
<br /> WELL DRILLER
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<br /> ........................................................................................:.. .AD....D.....R .ESS................................................................................ 0 .o
<br /> ADDRESS
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<br /> . . .................................................................... .PHON.E................................................................................ 0
<br /> PHONE
<br /> DESCRIPTION4. Sanitary Facilities: ° o
<br /> 1. Work:
<br /> 2No. Bathrooms '
<br /> . New Building Details • •••••
<br /> New Building n Type of C ns ction: No. Bedrooms o
<br /> Addition .......... .,,{,t,l .r. ............• • , , •• Septic Tank Size Gals. ..........
<br /> Sanitary Size ....9.`?'ql. ft. x .. .. ...:..4'ft. ••••••
<br /> ........ .
<br /> Filling/Grading4a. Absorption Field Site:
<br /> .......... Height............. Stories ............... c
<br /> Moving .......... Area Soil Type .................................... 3 i
<br /> ..........................I................ r
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<br /> Mobile Home .......... Slope ............................ ............. E
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<br /> Priv Pere. Rate ............................
<br /> Privy 3. Use (describe exactly, 1 family •.••.•
<br /> Well home, arage, motel, e I Dry Well
<br /> .......... /�, j ..........
<br /> Subdivision .......,., aJ�.,,e.� �c�/- r_.,eSeepage Trench .......... R
<br /> ..................................................
<br /> Camping Unit „ ,,,,,,,, Privy ,,,,,,,,,,
<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. Include road P e
<br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter {' a
<br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING i
<br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS.
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<br /> 5. Lot Size: Fig. A. 6. Location:
<br /> ................ ft. x .............. ft. — ............................... sq.ft. ...............................................................................
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<br /> Remarks ....J..GI..a..../``.: ... .'.'.9 '��/i�l.. ?..yt.”-t,....$. .5 °::^.....�4.....�?2......��,S�i�lu� , T x v
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<br /> Inspection Date . ....... . ...... ........................... U 'o 'o ��m
<br /> Zonin inistrator $ $ $ $ $ to
<br /> NOTE: A preliminary site inspection must be made an site approval granted on all structures involving sanitary facilitieS
<br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to
<br /> this application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build
<br /> Ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyer] here-
<br /> with is found to exist. Changes in plans or specifications shall not be made without approval of the Zoning Administrator.
<br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED.
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