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Burnett County Office of Zoning Administrator �' o
<br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT m 3.
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<br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 09
<br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the C i
<br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 i�
<br /> regulations of the State of Wisconsin. a =c
<br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT ;
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<br /> ADDRESS .. ........Y..h1...^....+.-./1...� •%..... ADDRESS.............................................................................
<br /> ADDRESS
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<br /> PHONE............................ ................................................................... ..............................................................................
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<br /> PLUMBER WELL DRILLER
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<br /> ADDRESS ADDRESSn C
<br /> ........................................................................................... .PH4O0- -.NE ............................. ....................................................... N
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<br /> DESCRIPTION 4. Sanitary Facilities: ° o
<br /> 1. Work: No. Bathrooms '-
<br /> 2. New Building Details """"" i o
<br /> Naw Building No. Bedrooms .... ,r-
<br /> .......... Type of Construction: '7d :-1�
<br /> Addition ,,,,,,,,,,,,,,,,,,,,,,,,,,,„ ,,,,,,,,,,,,,,,,,,,,,,, Septic Tank Size Gals. n 1
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<br /> Sanitary ... Size .............. ft. x .............. ft. ..........
<br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site:
<br /> Moving .......... Area ...........................................
<br /> Mobile HomeSlope .......................................... ^
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<br /> Privy Perc. Rate ................................... i
<br /> .......... 3. Use (describe -family '�
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<br /> Dry Well m
<br /> Well .......... home,garage, motel,etc.) ”""""
<br /> SubdivisionSeepage Trench .......... Z
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<br /> Camping Unit .......... .................................................... Privy
<br /> --_----- Seepage Bed-
<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 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. :1J
<br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. ,_ 0".
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<br /> 5. Lot Size: Fi9A. 6. Location:
<br /> ................ ft. x .............. ft. - ............................... sq. ft.
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<br /> Signature of ner or Agent Date � g
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<br /> Remarks
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<br /> InspectionDate ....................................... ....... ..... ...... ............. ....................................... v,�, o o u, m
<br /> Zoning dministrator g g $ g g M
<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.
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