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Burnett County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMITa 3. c UJ <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 ( l ;) <br /> regulations of the Stateof Wisconsin. a <br /> ST .Y ."! (L. !J f3 Twd S .. ..................................... F n <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT ; <br /> ................ <br /> ADDRESS ADDRESS m :� <br /> ......................................................................................... <br /> ADDRESS ADDRESS <br /> . ` <br /> . ...................................................................................... la f) <br /> ...............1(2114W.... ..... . <br /> PHO ..................................... PHONE <br /> .. .... ......... ......... .. . . . ................................./............................................. •t-.� <br /> PLUMBER WELL DRILLER ' <br /> 7 <br /> .................../�.�... ................�'"�1.�[p....T1. t1. - <br /> ADDRESS ADDRESS v .o <br /> ........ <br /> .............. <br /> ........................................................................................... .PHO-H-0-.NE...................................................................... Z N .: <br /> PHONE <br /> r (. <br /> DESCRIPTION 4. Sanitary Facilities: ° o P_ <br /> 1. Work: 2. New Building Details No. Bathrooms .......... c <br /> New 6ullding .,,. Type of Construction: No. Bedrooms ..3... <br /> Addition ••,,,,,,,,,,,,,, „•,• Septic Tank Size Gals. .......... sp('Q•� �� <br /> Sanitary .. ....v ...f... /D....4..0 y <br /> ........ .... .... <br /> y ...�.. Size ...�..�.... ft. x .........y. ft <br /> Filling/Grading Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Aree Soil Type .................................... r <br /> ......................................... C <br /> Mobile Home Slope .......................................... v •» <br /> .......... N H ; <br /> Privy 3. Use (describe exact) -family Perc. Rate ................................... 0 <br /> Well Dry Well <br /> ,......••, home,garage, motel,etc.) """"" <br /> subdivision .......... z <br /> Seepage Trench .......... o <br /> .................................................... <br /> __Camping Unit— .......... .................................................... Privy ....... : \ " kl <br /> ---------------------------------------- Seepage Bed------/ $ �. .. <br /> N <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. '� g <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at <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. <br /> ---------------------------------- ---------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: o <br /> ................ ft. x .............. ft. — ............................... sq. ft. ;l :� <br /> N O <br /> 0Olive <br /> (_ <br /> zwLOW-0-41 J, I � a <br /> 0i f�r Z <br /> 0 <br /> r e <br /> E. m <br /> _. _. m <br /> M "n•e am EL S <br /> a oa � CQQ <br /> y353 <br /> owo D� -i <br /> Nn S <br /> n ; <br /> 0 <br /> _ C <br /> A : A <br /> Signature of Owner or Agent Date c <br /> y " <br /> ............Remarks ............................................................................................................................................................. n <br /> ................................................................................................................. ....... .................. ........... ....................... <br /> : o <br /> 0 <br /> n T <br /> ...... <br /> N O N N m <br /> Inspection Date ....................................... ............ ............... cn u, ut o o u' m <br /> ........... ......... .......... . <br /> Zoning Admin rator g g g $ $ $ y <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities 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 been 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 APPROVED. <br />