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('/' /J"' I 1 i . <br /> Burnett County Office of Zoning Administrator o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3 <br /> o <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 agrees that all work shall be done In accordance with the requirements of the Burnett County Land Use m C <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. <br /> . . .. .. ...... ................................ . . . . . . . ........... . . . .......................0............................ C <br /> ' O <br /> . . . ...... . . . . <br /> OWNE Iplease p CONTRACTOR or SU RVEVOR or AGENT a <br /> .... .. . .... <br /> .......... <br /> .- . ....................................—................................. ........ d <br /> A DRESS <br /> .:. .............................................................0.............................. <br /> ADDRESS ADDRESS <br /> .......................................... �W <br /> PHONE PHONE <br /> loJ.'.. ..................................... .......................................... > <br /> PLUMBER WELL DRILLER ;Ch\ <br /> O <br /> .............. <br /> ........................................................................................... . ............................................................................ m O <br /> ADDRESS ADDRESS <br /> n O <br /> ........................................................................................... . ................................................—...............0....................... <br /> PHONE PHONE Zr <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> No. Bathrooms <br /> 1. Work: 2. New Building Details """"" o <br /> ,/ No. Bedrooms <br /> New Building ••••.!.... Type of Construction: """"" <br /> Addition .................................................... Septic Tank Size Gals. .......... <br /> Sanitary .......... Size .............. ft. x ft. """"" ' <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Soil Type .................................... <br /> .......... Area ........................................... � o i <br /> Mobile Home ..`. Slope .......................................... <br /> """""" <br /> Rate ................... rJ <br /> Privy .......... 3. Use (describe exactly, 1 -family Pere. <br /> Well ,......... home,garage, motel, etc.) Dry Well .......... l?J <br /> Subdivision Seepage Trench .......... of <br /> CampingUnit .......... .................................................... f . <br /> Seepage Bed ..•....... (� <br /> Location of proposed structures and existing structures,well, sewage systems, roads,etc., should be sketched in Fig. A. Include road ri� 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- Y' o- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING Ua `– <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. 11a o <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: M <br /> U•, <br /> 22 <br /> ................ ft. x .............. ft. —�1...17•..... sq.ft. ............................................................................... <br /> n <br /> N o <br /> o <br /> 3 ` . <br /> :N <br /> t0 y <br /> tN <br /> Qy �1 <br /> —3 F <br /> N � <br /> O <br /> Z <br /> 0 <br /> DO <br /> eriC 0, <br /> !�JN C <br /> O m y 6 <br /> Z 00 . n <br /> FT <br /> .. ....... .... ........................... C <br /> Signature of caner or Agent Date <br /> X S <br /> Remarks ......................................................................................................................................................................... m R <br /> � I � C <br /> ea <br /> ........................................................................................................................................................................................ .�f . . : : : : <br /> 11 <br /> ....................................................................................................... ..................... _ . i i <br /> o. .T <br /> rTInspection Date ....................................... .. ... ..... .....Z . .. . <br /> Zoning Admi strator <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 Me made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />