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Burnett County Office of Zoning Administrator K o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ;W 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 agr es that all work shall be done in accordance with the requirements of the Burnett County Land Use <br /> Ordinance, Sanitation CodWandithal o er applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 <br /> OWNease rint . .......................................................................................... m <br /> ,E�}44 /) _ �)^ CONTRACTOR or SURVEYOR or AGENT a <br /> (LF//(/ ...............�....C............. ......./ ............................................................................................ <br /> ES ADDRESS .. <br /> ....................................................r� .30 <br /> ADDR SS ADDRESS <br /> PHONE ............................. .P V ���� I ...................................... <br /> .......................................... <br /> .. <br /> PLUMBER W /�ER /,�rI' <br /> ........................................................................................... /......... (7 YV — \ <br /> ADDRESS _ 5 ...... a .... ....... ........ : 0 . <br /> A!,uD _ o i\T� <br /> l% < <br /> . . . ................................................................................... ............................................................................................ Z o' <br /> PHONE PHONE <br /> DESCRIPTION r <br /> 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms o <br /> New BuildingNo. Bedrooms .......... 'a <br /> .......... Type of Construction: <br /> Addition Septic Tank Size Gals. .......... <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... <br /> FillinglGrading Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area .......... Soil TYPe .................................... f' o <br /> ........................... . ... <br /> Mobile Home Slope .......................................... •+ <br /> Privy 3. Use (describe exactly, 1 -family Perc. Rate ....4.......................... ... <br /> Well �„ home,garage, motel, etc.) Dry Well <br /> Subdivision ,,,,,,.... Seepage Trench .......... <br /> Camping Unit .......... .................................................... Privy .......... r <br /> ...................4.............................. <br /> • Seepage Bed .......... <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig. A. Include road p <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- ,C a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING I < <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. G `� <br /> 0 <br /> ----------------------------- -- °{rl <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq. ft. <br /> ............................................................................... <br /> 'C <br /> vl <br /> vl <br /> 1J 0 <br /> o <br /> tfjUS� ���Uy o <br /> s � <br /> ELS <br /> T nr ` mF <br /> c w c m <br /> 1 c tn� a < n <br /> vrvi0 C m qac <br /> o <br /> Z o m a a m <br /> oM 3 <br /> 0 =' 70 <br /> vt — ° <br /> o <br /> S J� m <br /> Signature of Owner or Agent Date <br /> X <br /> m <br /> Remarks ......................................................................................................................................................................... m� p <br /> m <br /> .............. ..... <br /> ................ <br /> iCa <br /> Inspection Date ....................................... ... . .....:....9......�jnisjtor <br /> .............. o $ o Z m <br /> Zonin Adv $ $ $ 8 $ 8 V7 <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 he 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 be made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />