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Burnett-County Office of Zoning Administra or
<br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT
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<br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described nd 0
<br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of he
<br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws nd 3 •!J
<br /> regul tiorp of the State of Wisconsin. a
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<br /> OWNER (pie print) CONTRACTOR or SURVEYOR or AGENT
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<br /> ADDRESS ADDRESS
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<br /> ADDRESS ADDRESS '.o I '3
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<br /> PHONEPHONEK
<br /> PLKl .e.. ..... ..f..ry. ................................................... ............. .. .................................................................... ......
<br /> MBER WELL DRILLER 1
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<br /> ADDRESS ADDRESS0 C
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<br /> PHONE PHON........E
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<br /> DESCRIPTION4. Sanitary Facilities: 0 o
<br /> t. Work: No. Bathrooms
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<br /> 2. New Building Details •• •••••• :0 0
<br /> New Building Type of nstruction: No. Bedrooms ... ......
<br /> Addition ... ,,,,,,f ly.;;c,,,,,,,,,,, Septic Tank Size Gals.
<br /> .......... . ..
<br /> Sanitary ... ... Size ..;Q.*.... ft.°x ... ft. .. ..5.. i i
<br /> Filling/Grading .......... Height............. Stories ............ .. 4a. Absorption Field Site:
<br /> Moving .......... Area ......................................... Soil Type ............................. ...... '• r
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<br /> Mobile HomeSlope ................................... ...... v ..
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<br /> Perc. Rate ............................ ...... m
<br /> Privy .,.,,,,,,, 3. Use (describeexactl , 1 -family o
<br /> Dry Well m
<br /> Well ,,,....... home,garage,motel, a -- — i
<br /> SubdivisionSeepage Trench ... ...... o i
<br /> .......... .................................................. �.>
<br /> Camping Unit ... ......
<br /> .......... Privy.................................................... }�
<br /> Seepage Bed
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<br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fi A.
<br /> Include road setback,side and backyard dimension and location and setback from all bodies of water. If property is local ;d at —,
<br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersecton,
<br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS.
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<br /> 5. Lot Size: Fig. A. 6. Location:
<br /> ................ ft. x .............. ft. — ............................... sq.ft. ....................................................................... .....
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<br /> Signature of Owner or Agent Date g
<br /> Remarks m u,
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<br /> Ut�� � 'po m
<br /> Inspection Date ....................................... ... ........... .... . 9. ...... .............................. . m
<br /> Zonin Ad mistrator �S 8 0 0 $ o fA
<br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary fa ilities 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 beer 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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