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j L' <br />Burnett County Office of Zoning Administrator C V0 0 <br />APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. <br />o Q <br />TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < H <br />shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use CD c <br />Ordinance,/Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a G <br />CL <br />A <br />!..A.M.............................................................................. c............................. .�%Q <br />please print) CONTRACTOR or SURVEYOR or AGENT a <br />: <br />4 ; <br />ADDRESS ADDRESS °+ C� •� <br />h. <br />......... �.............. -,•._...................................... <br />i <br />................................ <br />PH E PHONE <br />PLUMBER WELL DRILLER <br />ADDRESS ADDRESS ID C) <br />........................................................................................................................................................ o <br />PHONE PHONE :q <br />Z y r ✓ <br />DESCRIPTION 4. Sanitary Facilities: ° o ° <br />1. Work: No. Bathrooms ° <br />2. New Building Details o <br />New Building .......... Type of Construction: No. Bedrooms �j � <br />Addition Septic Tank $ize Gals. .......... V <br />.... ........................... <br />Sanitary „jC,,,., Size .............. ft. x .............. ft. v <br />Filling/Grading .......... Height ............. Stories ...............Siti: <br />4a. Absorption Field i <br />Moving Area Soil Type.................................... r• <br />.......................................... o <br />Mobile Home Slope.......................................... id + <br />.......... <br />Privy ,,.,,,..., 3. Use (describe exactly, 1 -family <br />Perc. Rate................................... X <br />Well home, garage, motel, etc.) Dry Well .......... <br />SubdivisionSeepage Trench .........., ' <br />................................................... - <br />--Camping UnitPrivy <br />—............................................ s <br />Seepage Bed <br />------------------------------------------------------------ <br />Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road C: <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. 7 1 N <br />--------------------------------------------------------------------- <br />5. Lot Size: Fig. A. 6. Location: <br />................ ft. x .............. ft. — ............................... sq. ft..............................................................................., <br />.� m <br />N O <br />o <br />D <br />LOL <br />n <br />o :G <br />o <br />� s <br />CD <br />Z <br />0 <br />v <br />CD <br />CD <br />c CD w'v �.� <br />CD N CD <br />,< — co <br />ID M <br />Z 00 a 70 <br />o CL <br />0 <br />r V 0 M <br />.................................................... 1.................................. o <br />SigV'-re-of O er or Agent Date <br />X <br />Remarks' l%......a..ZJ-'"y`m.................................................................................................................... C . . . . . . <br />Co <br />............. <br />................................ ...................................... <br />.. ,G.......... ..... <br />69 <br />Inspection Date ....�r T ..� ./.......... .,..,.,. m <br />c,.ocno 1T7 <br />ZoningAdminis rator Jr J 0 0 0 0 0 0 N <br />VOTE: 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 />ng until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br />✓vith 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 />