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Burnett County Office of Zoning Administrator o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as r0- v <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use c ` ry <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. ma -CSS` ' \ <br /> » n <br /> .L� ... ) ...................................... H 5 <br /> K <br /> .... ................................................. ....................... . <br /> OWNER (please print) _CDWTRACTOR or SURVEYOR or AGENT m m <br /> ............................................................................ <br /> a <br /> ADDRESS ADDRESS � !... .......................................................... <br /> ........................................ ...... ............ .......... ....... ......... <br /> . . . ... . <br /> ADDRESS . .................................................................................... <br /> ADDRESS ...... � :� <br /> 'S <br /> . . . . .................................................................................... <br /> ........................................................................................... . . . . <br /> PHONE. ............................................................................... PHONE (�A <br /> ............................................................................................ -` <br /> PLUMBER WELL DRILLER <br /> .......... <br /> ........................................................................................... .ADD....R..ES....................................................................... .� <br /> ADDRESS S a1' <br /> c ;\ <br /> O' <br /> ........................................................................................... ..... - ............................................................................... p <br /> PHONE PHONE..... Z H r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms .......... <br /> New building No. Bedrooms ° .0 <br /> .......... Type of Construction: a t t <br /> .......... a ; <br /> Addition .......... .................................................... Septic Tank Size Gals. .......... <br /> Sanitary .......... Size .............. ft. x ft. <br /> FillinglGratling4a. Absorption Field Site: <br /> .......... Height............. Stories ............... <br /> Moving .......... Area Soil Type ......................... .......... I- <br /> ........................................... : o <br /> Mobile Home .......... Slope .......................................... �' » <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Well .,,.,.,,,, home,garage, motel, etc.) Dry Well .......... <br /> Subdivision „�/... page Trench .......... <br /> .. .................................................... See . <br /> Camping Unit .......... Privy .......... <br /> .................................................... Seepage Bed <br /> .......... <br /> --- -------------------------------------- ' cn <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road <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 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. p' <br /> 5. Lot Size: <br /> Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq. ft. ............................................................................... , <br /> N o <br /> ,a Cu <br /> o � <br /> o <br /> r s <br /> a <br /> m � <br /> io <br /> Z <br /> 0 <br /> v <br /> m <br /> 7J 9 N In Z <br /> N C m n m <br /> y =nm <br /> Z o o a 31 <br /> o n¢s 3 <br /> (A <br /> y <br /> Signature of Owner or Agent Date - <br /> T <br /> Remarks ......................................................................................................................................................................... .� m0 <br /> Cc' <br /> ....................................................................................................... <br /> p <br /> Inspection Date ....................................... <br /> o u ', ER o m <br /> tor $ 899980 <br /> Z' Adm�istraonin <br /> NOTE: A preliminary site inspection must be made and 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 riot 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. <br />