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Burnett County Office of Zoning Administrator Ln -- 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 located as .< °H 0
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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 Land Use me y
<br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 M. N
<br /> S Cu lirrA 07✓
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<br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT C
<br /> .......................... ........... .......s!a.3................. d �
<br /> ADDRESS ADDRESS
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<br /> ADDRESS . .......................................................................................... �
<br /> ADDRESS
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<br /> PHONE . ..........................................................................................
<br /> ........................................................................................... PHONE 'J
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<br /> PLUMBER WELL DRILLER i
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<br /> ADDRESS .............................................................. '
<br /> ADDRESS ..............................
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<br /> PHONE PHONE
<br /> DESCRIPTION 4. Sanitary Facilities: ° o 0
<br /> 1. Work: 2. New Building Details No. Bathrooms v
<br /> New Building ,,,,,,,,,, Type of Construction: No. Bedrooms
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<br /> Addition .......... .................................................... Septic Tank Size Gals. .......... <
<br /> Sanitary .......... Size .............. ft. x .............. ft. ..........
<br /> Filling/Grading ,,,,,,,,,, Height............. Stories ............... 4a. Absorption Field Site:
<br /> Moving .......... Area Soil Type .................................... r
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<br /> Mobile Home Slope
<br /> .......... P ............................ ............. ..
<br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... jia,
<br /> Well ,,,,,.,.,, home,garage, motel, etc.) Dry Well .......... i N
<br /> Subdivision ,,p . Seepage Trench .......... J, i
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<br /> Camping Unit ,,,,,,,,-, Privy `
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<br /> .................................................... Seepage Bed
<br /> .......... :Y
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<br /> Location of proposed structures and existing structures, well, sewage systems, roads etc.,should be sketched in Fig, A. Include road Q
<br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter o_
<br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <
<br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o�
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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 C
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<br /> Remarks ......................................................................................................................................................................... m m
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<br /> Inspection Date ....................................... Q..'. .t,1. ..��..t.G.f2Z.. .... ..... \e'er u 8 o U o 8 m
<br /> Zoning Admator ��� '^ $ 8 8 8 $ $ CIt
<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 fie 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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