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Burnett County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. 3j <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 3 0 <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 nd <br /> regulati s of the State of Wisconsin. ,.�py�� <br /> ................................ .. .. ... . ............. 7n 2.OWNE lease print CONTRACTOR or SURV OR or AGENT <br /> k........................................... .. <br /> ADDRESS O . ... .................................................. ...... <br /> ADDRESS <br /> . . . ................................................................................ .ADDRESS..................................................................... ...... :�, <br /> ADDRESS :L1 <br /> PHOt�"l�""" ' PHONE i vV <br /> . . .. . .. ..... .`................................................... . ... ....... . .. . ................................................................ ...... <br /> PLUMBER . . .� i✓I <br /> WELL DRILLER <br /> ........................................................................................... O <br /> AODRESS . ................................................................................... . <br /> ADDRESS n O 3"'? <br /> . . . ................................................................................... . . . . ........................................................................... ...... ~' .: <br /> PHONE PHONE.. Z N <br /> r <br /> DESCRIPTION <br /> 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms �-- <br /> 2. New Building Details <br /> New Building Type of Construction: No. Bedrooms ° <br /> x R <br /> Addition r M4 Septic Tank Size Gals. <br /> F........g...............�.p............. :cam 9 <br /> Sanitary ..... Size ...ck�r.... ft. x ..'+�...i...... ft. . . .... <br /> Filling/Grading ,,,,,,,... Height.....II...��.. St ies ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........... �`.�. Soil Type ............................. ...... i i .r i <br /> .............. <br /> Mobile Home Slope ................................... ...... <br /> .......... .9 <br /> Privy Perc. Rate ............................ ...... m <br /> .......... 3. Use (describe exactly 1 -family <br /> Well .......... home,garage,motel, a :t Dry Well ... ...... <br /> Subdivision ,,,,,,,,,, Seepage Trench ... ..... Z. 4 <br /> .................................................... <br /> Camping Unit .......... .................................................... Privy ... ...... ' <br /> 5 i <br /> Seepage Bed <br /> __ �. .....(` L . <br /> Location of proposed structures and existing structures well sewage systems, roads, etc., should be sketched in Fig A. <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. It property is local d at l <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. i <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> __________9_ :. :� <br /> 5. Lot Size: Fi A. 6. Location: .�l) [ <br /> ................ ft. x .............. ft. . ............................... sq.ft. ........................................................................ ...... <br /> c � <br /> 1 �_. I `t�"I. 0 `� 3 <br /> o <br /> s <br /> � a <br /> 1 [ Z o <br /> o <br /> v <br /> Z7 .N M (/) rD co <br /> ° <br /> c: n n <br /> S N : `C N 0 n m <br /> D - <br /> n o 0 <br /> t m zi o C <br /> ........... ..... ............................................... .............. . ^. <br /> M <br /> Signatur of O r or Agent Date C <br /> Remarks n ' �c <br /> .. °::.... ..'.`..4.. ..l;..F........'.......................................................................................................................... .. N :r : f <br /> N <br /> N <br /> .......................................................................................................... . .... ................ S <br /> W N r N <br /> ..................... .. <br /> T <br /> Inspection Date ....................................... .. ... ... ... ..... ....................................................... .. u, N N O O N m <br /> Zoning Administrator Mis <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary faci ities 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 ssued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or sl ecifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPMOVED. <br />