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Burnett County Office of Zoning Administrator 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3 o yJ <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < .n <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m W <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 C- <br /> s <br /> elf..C �� f �....... ............ ......................... :.........� �.............................. _ o <br /> OWER (please print) CONTRACTOR or SURVEYOR or AGENT a <br /> ��,QQ� ........................................................... - t:..... ....syr/` ............................... <br /> ADDR/ESS� ADDRESS <br /> .....7.:::.::::.... "': .y............ ............................................................................................ <br /> ADDRESS ADDRESS <br /> i\. <br /> ........................................................................................... .P..HONE......................................................................................... <br /> PHONE <br /> ........................................................................................... WEL. . . ..L...D...RI..LLER............................................................I.............. <br /> PLUMBER <br /> O_ <br /> ........................................................................................... ........RES.................................................................................... m M <br /> ADDRESS ADDS <br /> n o <br /> ........... <br /> ........................................................................................... . . ......................................................................... <br /> PHONE PHON.... .. E Z N <br /> r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms .......... o \ <br /> New Building .......... Type of Construction: No. Bedrooms .......... <br /> Addition .................................................... Septic Tank Size Gals. .......... <br /> Sanitary Size ft. x ft. ••.......• <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: i <br /> Moving .......... Area Soil Type .................................... <br /> Mobile Home .......... Slope .......................................... } .� <br /> Priv Perc. Rate ................................... i <br /> Privy .......... 3. Use (describe exactly, 1 -family <br /> Well ,,,,.,,,,, home,garage, motel, etc.) Dry Well .......... i Z <br /> :o <br /> Subdivision ✓,,,, Seepage Trench .......... ro <br /> ..... .................................................... ; <br /> Camping Unit .......... Privy .......... tt <br /> .................................................... Seepage Bed 'N <br /> ----- — <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig. A. Include road L <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter <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 /> o <br /> ............... ....- ` O <br /> q. ..................... o cb <br /> � ft. x ............ . ft. — / ..../..y..�................ s ft. ............................. .a <br /> I I <br /> 0 <br /> r o <br /> Q 1 <br /> N VI <br /> O <br /> 0 <br /> m <br /> � 4 <br /> k X <br /> MNm 9 rp <br /> W t <br /> a a <br /> a < — a m <br /> -' m <br /> Z y n <br /> 61.on <br /> rn <br /> : Co rn <br /> y-..a...s.- ........... : <br /> Signature of Owner or Agent Date W o <br /> X S <br /> Remarks ......................................................................................................................................................................... 0 <br /> m <br /> I <br /> ................................................................................................ <br /> °o X . . . . . . T <br /> m <br /> Inspection Date ....................................... !??....... ...........:..9.Adm'n... ..... istrator K...............✓............... <br /> Zoning 18 ur u o ur o v, m <br /> . . 8 8 8 8 8 8 0 <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 tie made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />