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Burnett County� •_. Office of Zoning Administrator <br />r ' <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 Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. <br />... � ftA.................................. <br />��...%. ..................................................... <br />OW R (pleas print) CONTRACTOR or SURVEYOR or AGENT <br />t.................. Q ............ -........................................................................................... <br />AD ESS � r ADDRESS <br />1.............................................. <br />....... ................. <br />ADDRESS ADDRESS <br />............................................................. <br />PH E <br />P c U�. . . . . (44 <br />...... ... ..................... <br />PLU ER <br />..................... <br />ADDRESS <br />.............................................. <br />PHONE <br />DESCRIPTION <br />1. Work: �^ <br />New Building <br />Addition <br />Sanitary <br />........................................................................................... <br />PHONE <br />...........DRI............LLER ..................................................................... <br />WELL <br />� <br />-:Z <br />ADDRESS <br />: !� <br />............................................................................................ <br />PHONE <br />2. New Building Details <br />Type onstruction: <br />......... .`...--:....... <br />Size 3 11� ft x 1 . <br />4. Sanitary Facilities: <br />No. Bathrooms <br />No. Bedrooms <br />Septic Tank Size Gals <br />ft. /Q.A..ci <br />Filling/GradingHeight ............. Stories ............... 4a. Absorption Field Site: :Si7 <br />MovingArea Soil Type .................................... r- <br />.......... <br />Mobile Home Slope .......................................... 'a <br />Privy .,.,...... 3. Use (describe exactlyPerc. Rate ................................... <br />, -family <br />Well home, garage, motel, Dry Well t, <br />Subdivision ,,, Seepage Trench ... I...... <br />.................................................. <br />Camping UnitPrivy <br />................................................... r.J <br />Seepage Bed o�.,�.3� <br />------ ---------------------------------- <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- fl <br />section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING y•n.�7, <br />STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS.h <br />D <br />---------------------------------------------------------------------- <br />5. Lot Size:�^ Fig. A. 6. Location: : C, t�1 <br />................ ft. x ft. � +� sq. ft. G ~ i■ a <br />PH <br />w� <br />i� <br />Z <br />O <br />t1l <br />(D <br />3 <br />N <br />C: <br />rn <br />Q <br />LN <br />/Pp <br />,e Y L <br />j� <br />....... .................... .. ��s� <br />............... <br />Signature of Owner or Agent Date <br />Remarks........................................................................................................................................................................ <br />.......................................................................................................... <br />.............. ........... .. <br />Inspection Date .......................................<......... ..............3............. <br />Zoning Admin�i, <br />VOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br />)efore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br />:his application before a permit will be issued. Do riot 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 />with 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 />rn <br />�o <br />N <br />: !� <br />e3 <br />:4., <br />m <br />L <br />(n r <br />CD C w <br />(on p0 Z <br />c (D <br />-6 CJn C <br />N <br />G <br />cCD� <br />h CD <br />m <br />Z <br />o <br />vy <br />a <br />- <br />°v CDm <br />vo <br />c <br />X <br />-n <br />CD <br />m <br />p <br />Co <br />o : <br />1n <br />6: <br />o�oco <br />o�m <br />000000N <br />VOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br />)efore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br />:his application before a permit will be issued. Do riot 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 />with 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 />