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Burnett Cour' - Office of Zoning Administre for WA <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT W3. <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws nd <br /> regulationsof the Sij <br /> 11ta;;e of Wisconsin. <br /> (1T�. ...K.t>. .. ................................................. .....) . . .. T...�cd.l:.>/�'`�.IFI!.yG.'�} ................. ..... <br /> OW Riposte lintl CONTRAC R or S RVEVOR or AGENT / s <br /> ..... .. <br /> .�..,. ...... . ... �+. ... x..... ��... ......... a <br /> A . . .ESS ...�. V11..1�..... �:.1 ...................... .QD� +.?.�..-.�...1�..)..� ...n..J.7.i5...�..1............... ...... � <br /> : 1 <br /> ADDRESS ADDRESS Cl 1 <br /> PHONE ............................................................................... PHONE <br /> . . ..................................................................................... ...... v' <br /> PLUMBER WELL DRILLER <br /> v <br /> ADDRESS ADDRESS ono <br /> on 0 O <br /> ........................................................................................... .PHO-H-0-.... <br /> NE.......................................................................... ...... <br /> PHONE Z <br /> DESCRIPTION r <br /> 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms o <br /> New Building Type of Construction: No. Bedrooms ... ...... <br /> Addition .......... .................................................... Septic Tank Size Gals. ... ...... ,7 i <br /> Sanitary .......... Size .............. ft. x .............. ft. ... ...... i <br /> Flllingl Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Area Soil Type ............................. ...... r <br /> Mobile Home .......... Slope ................................... ...... ^ <br /> PrivPerc. Rate ............................ ...... m <br /> Y .......... 3. Use (describe exactly, 1 -family � <br /> Well home,garage, motel,etc.) Dry Well ... <br /> Subdivision ,., Seepage Trench z <br /> ... r p <br /> Camping Unit .......... .................................................... Privy <br /> Seepage Bed .. .(Y))),-f��lJ <br /> ------------------------------------------------------------------- -- I i •Vl <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. <br /> Include road setback,side and backyard dimension and location and setback from all bodies of water. If property is located at (�"-`r <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersect on. v<-, <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> _____________ - <br /> 5. Lot Size: Fig. A. 6. Location: <br /> I <br /> ........... .... ft. x .............. ft. - ............................... sq. ft. ....................................................................... ....... <br /> CSS") I� <br /> O <br /> ! T <br /> m !_ <br /> Z <br /> 0 <br /> a <br /> O <br /> m <br /> N c � Wm 0 coco <br /> o Q < > > n - — m <br /> M Nam - o. n any <br /> o < w c <br /> O <br /> o' i5u : ,2 a <br /> o c ^ m <br /> 2 J : 0 <br /> C <br /> '~ A . � M <br /> ........................................................................... ...................................... a , <br /> Signature of Owner or Agent Date <br /> Remarks <br /> ..................................................................................................................................................................... ... n `- <br /> n �• <br /> � H <br /> o : 8 <br /> 0 <br /> _ . ..,I....................... T <br /> ] NmN 0 + Nm <br /> Inspection Date ....................................... :...... !0-nv.. fJ4... ... 9998 8 8 y <br /> Zoning Administra o <br /> NOTE: A preliminary site inspection must be made and site app' "l granted on all structures involving sanitary fac Iities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this appli ation before a permit will <br /> be issued. Do not purchase or install a septic tank,do any plumbing or start any building until a permit has been issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />