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Burnett County Office of Zoning Administrator
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<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 and
<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 and
<br /> regu-/la1tions of the State of Wisconsin. ....................
<br /> Tjio.�a . Vtl...../ ...... ..........
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<br /> pl rinNTFIjNCTOR
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<br /> or SURVEYOR or AGENT
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<br /> ADDRESS ADD ES m
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<br /> ADDR,ESS .. ............. . . ... .ADDRESS
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<br /> PHONE PHONE o I
<br /> PLUMB R WELL DRILLER
<br /> /f10 ��.�W.S................................................. ............................................................................................ o Flu+
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<br /> PHONE PHON...... ..E Zv°, r
<br /> DESCRIPTION 4. Sanitary Facilities: ° o °
<br /> 1. Work: 2. New Building Details No. Bathrooms ...
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<br /> New Building / No. Bedrooms
<br /> .... .. Type of Construction: •••••••••• �— �
<br /> Addition Septic Tank Size Gals.
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<br /> Sanitary ... Size .. .�... ft. x .... y�. ft. .......... .
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<br /> Ficin /Gradin 4a. Absorption Field Site:
<br /> Filling/Grading .......... Height...$....... Broyles ...j..........
<br /> Moving .......... Area ......... ' Soil Type ..........................I......... ✓,� r i
<br /> Slope °
<br /> Mobile HomeSl .......................................... � �+
<br /> Perc. Rate ...................................
<br /> Privy ,,,,,,,,,, 3. Use (describe exactly, 1 -family o ;o .
<br /> Well , ........ home, arage, motel,etc.l Dry Well ..........
<br /> Subdivision ..,,,,,,,, ..�,,,V1624,2 a1"' Seepage Trench .......... o EA
<br /> Camping Unit / Privy ... ,^` ",
<br /> .......... .................................................... y r1
<br /> ------------------------------------ Seepage Bed--------�A7 r y
<br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. ° f'
<br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at YnJI i
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<br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection.
<br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. 0
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<br /> 5. Lot Size: �� Fig. A. 6. Lo I n:
<br /> ...1.�/�..� ft. x ,alv. . — .�...........1�............ sq. ft.
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<br /> Lot 1,A)IF �Otkiivi � a
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<br /> Signature of/Owner or Agent Date E ly. o
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<br /> Remarks ..1.�:.:....f:.,/':u.......�.''..�1.�.....:........................................... .................................................................... m<- .
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<br /> Inspection Date ..1..-'1 �— �� .°�' . °�' J N
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<br /> Zoning ministrator I 8 0 8
<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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