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Burnett-County Office of Zoning Administrator 0 o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. <br /> o :K3 <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as < v, <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use - C :� <br /> Ord�dinance, Sanitation Codee, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 M \I \ 'V <br /> ..�c�e..uwr N � o <br /> OWNER (Please pr t) CONTRACTOR or SURVEYOR or AGENT o. <br /> ...... .............. .. ....... .................... ............................ d <br /> A DRE S ADDRESS .� <br /> w� 3 f�f.3................................. . . . . . ........... ......... ...... ...... .............. .............................. <br /> ......... ............................. <br /> ADDRESS � ADDRESS <br /> ........................................................................................... ............................................................................................ <br /> PHONE. ............................................................................... PHONE <br /> . . . ..................................................................................... <br /> PLUMBER WELL DRILLER �\ <br /> ........................................................................................... ......... 'E'S- ............................................................................. O : k ADDRESS ADDRESS [ Cc.................................................. ...... ...... ....... .. ............. ................ .... ..................... ............................... O <br /> PHONE PHONE Z <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> 1. Work: No. BathroomsO <br /> 2. New Building Details •••• o <br /> New Building .,,,,,,,,, Type of Construction: No. Bedrooms .......... ' a <br /> Addition Septic Tank Size Gals. .......... <br /> :'Q, <br /> Sanitary .......... Size .............. ft. x .......... <br /> Fillingf Grading ....,..,.. Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area Soil Type .................................... i <br /> ........................................... o <br /> Mobile Home .......... Slope .......................................... o <br /> Privy .......... 3. Use (describe exactly, 1 -family Pere. Rate ................................... 3 ;� <br /> Well home,garage, motel, etc.) Dry Well .......... F <br /> Subdivision ✓,,,, Seepage Trench <br /> .......... m <br /> Camping Unit .......... Privy <br /> .................................................... Seepage Bed R <br /> ----------------------------- zt <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig. A. Include road o- <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- w 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. h 7 <br /> o ° <br /> ------------------------------- t <br /> 5. Lot Size: Fig. A. 6. Location: N <br /> r\ <br /> .... ft. x .............. ft. . ............................... sq. ft. o i <br /> 0 <br /> A <br /> \ <br /> N vJ O <br /> O <br /> 7 J <br /> V4161 $ ! <br /> N <br /> Z <br /> - o <br /> M <br /> M <br /> 4\ <br /> N 9 W W Z <br /> o <br /> m a <br /> o <' <br /> Z o > gm <br /> a <br /> ........................................................................... ...................................... C <br /> Signature of Owner or Agent Date <br /> X <br /> Remarks ......................................................................................................................................................................... m m <br /> v <br /> ........................................................................................................................................................................................ <br /> ......................................................................................................... .......... <br /> .................. . ... .... <br /> Inspection Date ....................................... �... ........... i to U'' 0 8 0 m <br /> La..................... m <br /> Zoning Admi Istrator 8 8 5 8 8 8 y <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structu/les 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 he made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />