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Burnett County ` "' Office of Zoning Administrator 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMITd 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m <br /> Ordi nce, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a rr N <br /> a <br /> O <br /> ...1.4. .............dd..4 N................................. ........................................................................ N s� <br /> . . . ...... . . . . <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT a V <br /> f y (Q tv rs�c e.� `�r Dr a o . <br /> ... ......... ................................k-. <br /> ADDRESS ADDRESS i <br /> 1J�'.X s`fi.........5r PGu MI.h.:.......5SI/. ............................................................................... v :� '3 <br /> ................. ......................... • <br /> ADDRESS ADDRESS T4�0 <br /> .... .............. ............................................. ...........................................................,.................... <br /> P ...E.. PHONE )v <br /> iuj <br /> PLUMBER WELL DRILLER <br /> .......... <br /> . . . . . ..................................................................... <br /> ADDRESS ADDR. ESS 0 00 <br /> PHONE PHONE Z r •:Y+S <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details ••••••• ;R, o <br /> New Building .......... Type of Constructio No. Bedrooms �. o <br /> Addition VIZ... .. <br /> f I rr� Septic Tank Size Gals. <br /> ...... <br /> Sanitary Size .............. ft. x .............. ft. :p <br /> . Li <br /> Filling Height............. Stories ............... 4a. Absorption Field Site: E r i <br /> Moving Area .... . ................. ...... Soil Type ......... <br /> ....... ................ i r <br /> Grading Slope .......................................... ° <br /> Mobile Home 3. Use (describe exactl family Perc. Rate .................................. <br /> Privy .......... home,garage,motel,etc.) Dry Well <br /> Well Seepage Trench .......... �e <br /> Subdivision Privy i <br /> ......... .................................................... <br /> -- --------------- — Seepage Bed xa 0 <br /> ------------- — ------- ------------------------------- T rn m <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- ( a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING r- <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. = <br /> o' <br /> --------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. <br /> ................ ft. x .............. ft. — .........j <br /> ..A d' . ..... sq.ft. <br /> EC <br /> N O <br /> O 7 <br /> 7 <br /> O <br /> P 0 <br /> V <br /> 6c: C M <br /> �o cn r 'D CO <br /> d <br /> N a C: �'a m <br /> Z O�•m �_ <br /> O > <br /> N <br /> M <br /> 6 ' �d - ��- <br /> ................... ................ . .................. : p <br /> E C <br /> Signature of Owner Agent Date ° X <br /> -t x m <br /> Remarks ........................ m i O <br /> M <br /> ........................................................................................................................................................................................... O •�I <br /> e : <br /> / Wi <br /> -n................................ ocnovo m <br /> Inspection Date ....................................... m <br /> Zoning Administrator 0 0 0 0 o N <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 he made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />