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Burnett County Office of Zoning Adrninist�ator d 0 0
<br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3
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<br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and loclted as •� ,� -^
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<br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County La A Use
<br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wis.onset. 3
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<br /> OW R (please print) C RACTPR or SURV�YOR or AGENT a --
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<br /> ADDRESS ,. ACPR,ESS .... ............. ..... . W
<br /> Y �� �.......I .... ADDRESS. .. ........ .............. ............ ...... . . ..... . .
<br /> ADDRESS ` _>
<br /> PHONE PHONE r
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<br /> PLUMBER WELL DRILLER
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<br /> ADDRESS ADDRESS m C) ,..i
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<br /> DESCRIPTION 4. Sanitary Facilities: E, o
<br /> 1. Work: 2. New Building Details No. Bathrooms o
<br /> New Building .......... Type of Construction: No. Bedrooms .......... a
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<br /> Addition .......... .................................................... Septic Tank Size Gals. .......... <
<br /> Sanitary ,,,,,,,,,, Size ft. x ft. '• '•• ••'
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<br /> Filling/Grading ,,,,,,,,,, Height............. Stories ............... 4a. Absorption Field Site: (= i
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<br /> Moving Soil Type ....................................
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<br /> Mobile Home .......... Slope .........................I................ ..
<br /> Privy ...,,,,.., 3. Use (describe exactly, 1 -family Ford. Rate ...................................
<br /> Well .......... home,garage, motel, etc.) Dry Well .......
<br /> subdivisionSeepage Trench ....... ^�-
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<br /> Camping Unit .......... ........................... . ...................... Privy
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<br /> ............ Seepage Bed .......... 04J :
<br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be, sketched in I-iq A- Inclu e road Q
<br /> setback, side and back Yard dimension and location and setback from all bodies of water- If property is located at a hlghwa Inter- tT a
<br /> section, show the intersecting highways and the setbacks required along them and at the intersection- CLEARLY LABEL EXI 3TING 5.
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<br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. :
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<br /> 5. Lot Size: Fig. A. 6. Location: a
<br /> ...... ......... ft. x .............. ft. ............................... s4.ft.
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<br /> Signature of Owner or Agent Date �
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<br /> Remarks ......................................................................................................................................................................... In m
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<br /> mInspection Date ..............•........................ ....... ...
<br /> Zoning inistrator T
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<br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures if volving sanitary facllitlus
<br /> before construction Can begin. In the case of sewerage disposal systems, a copy of the percolatior test must be attached to
<br /> this application before a permit will be Issued. Do not purchase or install a septic tank, do any plt robing or start any build-
<br /> ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the in ormation conveyed here
<br /> with is found to exist. Changes in plans or specifications shall not be made without approval of tie Zoning Administrator .
<br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED.
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