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Burnett County Office of Zoning Administrator 0 o c <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT a 3 <br /> _ o C <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as C <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m m <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> OWNER (please print)�. COONNTTR,AjCT0 R or SU/R'V/E/YOR or AGENT. . .(/✓ /! : `ta:.,...fa/.1.....:S............................................ a N <br /> ADDRES 4 ADDRESS _ <br /> w/.... ............. ............................................................................................ \ <br /> sr� ................:.... ......... .. . <br /> ADDRESS ADDRESS <br /> .................................................... <br /> .. ........................................................................................ . .PHONE. N"'E" ........................... <br /> PHONE <br /> ................. <br /> ........................................................................................... .WE... ...L.L. DRI. .'Ll <br /> LL.E..................................................... <br /> PLUMBER R <br /> O <br /> ADDRESS ADDRESS <br /> � o <br /> ........................................................................................... . .. ................................................................................... o' <br /> PHONE P..HONE.... Z H <br /> r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms .......... o C� <br /> New Building , .....,., Type of Construction: No. Bedrooms .......... <br /> Addition .................................................... Septic Tank Size Gals. .......... <br /> .......... <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: i <br /> Moving .......... Area ........................................... Soil Type .................................... r i <br /> n O <br /> Mobile Home .......... Slope .......................................... o <br /> 3 <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Well ,,,....... home,garage, motel, etc.) Dry Well .......... :o '• <br /> Subdivision ..... .... Seepage Trench .......... <br /> .............. ..................................... <br /> Camping Unit .......... Privy .......... tt <br /> .................................................... Seepage Bed .......... <br /> ---------------------------------------------------------------------- Y <br /> n <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc.,should be sketched in Fig. A. Include road C <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter t•' 9- <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. <br /> 0 0' <br /> --------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x ............./.. ft. . ..........rn...... sq.ft. ............................................................................... o C <br /> ��Ee� S! ' <br /> ^. <br /> IN5-6 <br /> � o <br /> RJ <br /> Z <br /> _ I m <br /> JC <br /> � rnr v n+ m Z <br /> w <br /> m a < <br /> m - m <br /> < a c m <br /> - m <br /> z o' n 70 <br /> 0. <br /> b <br /> : C o m <br /> .... � W_ p <br /> Signature of Owner or Agent Date <br /> X <br /> Remarks ......................................................................................................................................................................... T : m <br /> m <br /> ...................................................................................................... ... . .......... 4 <br /> o m <br /> NN , m , Nm <br /> Inspection Date .........4............................. .qua.. ....:......:..9.......... ...............✓............... : i8 u v, o u, o u, m <br /> Zonin Adm nistrator K 8 8 8 8 8 8 N <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 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 conveyed 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 />