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Burnett County Office of Zoning Administr itor Ew c <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT g' 3. <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work describec and p 0 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements o the c <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the law and <br /> regulations of theeof Wiscon in. 3, <br /> . (please Drintl CONTRACTOR or SURVEYOR or AGENT <br /> : <br /> .? .......` ` ...........................................4.. ....... .................................................................................... ....... n <br /> ADDRE S ADDRESS % <br /> LC <br /> ..................................................................... ....... <br /> ADDS ADDRESS <br /> .1.. ............................................ ...................... ...PHONE f <br /> p�Q} <br /> :V \' <br /> PLUMBER WELL DR11 ILLER <br /> O <br /> ADDRESS ADDRESS 4 <br /> G <br /> PHONEPHONE........................................................................ ....... <br /> DESCRIPTION Z r <br /> 4. Sanitary Facilities: <br /> 1. Work: 2. New Building Details No. Bathrooms y . <br /> New Building No. Bedrooms .. R <br /> Type of Construction: '• <br /> Addition .., ,�•,Y Septic Tank Size Gals. .. .r.J.� <br /> Sanitary .......... Size ../ .... .ft. x ..... ft. .. ...... i <br /> Filling/Grading .......... Height..[J.r Stori ....� .. 4a. Absorption Field Site: <br /> Moving �+["�' g� f�,� Soil Type ....`.7.C.T.{S.� ` 'r. <br /> .......... Area .�. -1...:.rl. k:L�... 1...... ...... ....... <br /> Mobile Home Slope .................................. ....... O <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ........................... ....... <br /> Well .......... home,garage, mo el etc.) <br /> Subdivision .,.,._. . �' tf'� !1� Seepage Trench z <br /> . . ....... ................. .. .. ....... 0 <br /> Camping Unit .......... .. .... .... ..... Privy .. ....... — <br /> {..Q.sc..h............................. : <br /> Seepage Bed .. ...— :� i <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. :` C <br /> Include road setback,side and backyard dimension and location and setback from all bodies of water. If property is locaiadat <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. I o <br /> ------------------------------------------------------------------- -- <br /> 5. Lot Size, Fig. A. 6. Location: <br /> ..�7.C./....... ft. x ..<..!.F.. ft. — ............. sq. ft. i ? E <br /> IN p' <br /> O <br /> J <br /> O <br /> OC+' o <br /> T <br /> o Z <br /> G <br /> 1 M (n vt/) rD lP y <br /> m Nn•c � n n — y <br /> 1 0_ . <br /> om •< wr m <br /> o no m D <br /> N� n <br /> n ; y <br /> a m <br /> �-: . ...... .. . ............ � _ <br /> k A : m <br /> ignature of Owner or Agent D to o <br /> �-- � Baam <br /> Remarks ...... <br /> ...1..15. !.l.l.l..f.L�. ..... ...N...m.l.. 7 a <br /> ..... <br /> ........................................................................ <br /> ........................................................................................................ .. .......................... .. .. .. ................... .......... <br /> Q O . <br /> Inspection Date ..................4.................... .. . . . �i.r... ... A �-- W ..... .. ... N (OT (NT O $ m <br /> tonin Administrator $ $ $ y <br /> NOTE: A preliminary site inspection must be made and site app, val 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 appli ation 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 E pecifications 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. <br />