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Burnett County Office of Zoning Administrator
<br />APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT
<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
<br />Ordinance, Sanitation
<br />%%Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin.
<br />....D a.. v. ......1..�G. .. l � . t- ................................. .................. 77:7 ................................................. I ...........
<br />OWNER (plea print) CONTRACTOR or SURVEYOR or AGENT
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<br />ADRESS ADDRESS
<br />�r!11��►,!.../.�..,sem-.r�..�...................
<br />............................................................................................
<br />ADDRESS ADDRESS
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<br />PHONE - .E .............................. 1.... q - .
<br />.............................................................................................
<br />.. PHONE
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<br />PLUMBER( y� WELL DRILLER
<br />......................................................................................................................
<br />ADDRESS ADDRESS
<br />4 7./.,-................................. ............................................................................................
<br />PHONE PHONE
<br />DESCRIPTION gr��t y y, 4. Sanitary Facilities:
<br />1. Work: 2. New Building Details No. Bathrooms
<br />ew t3uildin .......... Type of Con truction: No. Bedrooms ..✓.......
<br />Addition rj,G„ ,f -••• h Septic Tank Size Gals. ,�L
<br />S star .......... Size ...... ,........./'.
<br />v�'.... ft. x ...g.1... ft.
<br />Filling/Grading g 4a. Absorption Field Site:
<br />,.....,,.. Height ............ Stories .....�..... .
<br />Moving .......... Area .....$ -:1 Soil Type .... ��
<br />JV ..................... Slope ..
<br />Mobile Home
<br />.... Perc. Rate ....
<br />.. .........................
<br />Privy ,......... 3. Use describe exactly, 1 •family
<br />Well ? .......... home, garage, motel, etc.) Dry Well
<br />Subdivision .......... Seepage Trench ..........
<br />...................................................
<br />Camping Unit ,,,,,,,,,, Privy ..........
<br />.................................................... Seepage Bed
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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
<br />setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter-
<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.
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<br />5. Lot Size: �! Fig. A. 6. Location:
<br />.,1,l,12..... ft. x . ft. —�y pJ. ! !....... sq.
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<br />Signature of O ner or Agent ate %—�7�� �1)
<br />Remarks .... J..13.....,,..... ....... i 7..... ... ✓.. .57Yv%l/..l;J .......�...Filr�( L1�., 1:T ...... - x
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<br />�rs,�. I%d........�!Y!�! .....�.......... /9.......l at,.��d'..`� f`t.............
<br />Inspection Date . �.. ............. ... :: o N o v o - m
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<br />f Zoning Adminis rator I'll 0 0 0 0 0 o N
<br />VOTE: A preliminary site ins inspection must be mWe and site approval
<br />p y p approval granted on all structures involving sanitary facilities
<br />)efore construction can begin. In the case of se"v,drage disposal systems, a copy of the percolation test must be attached to
<br />:his application before a permit will be issued. Do not purchase or install a septic tank, do any plumbinq or start any build -
<br />ng 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 Adm inistrator.
<br />SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED.
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