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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 Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. <br />....(�.�..N�.N................................... ............ .... ..."........................ <br />OWNER (please print) CONTRALTO or SURVEYOR or AGENT <br />................................................................................... <br />........... . <br />ADDRESS ADDRESS <br />.. A `� ... ......... s.y..t.s............ <br />............. . <br />ADDRESS ADDRESS <br />..:��-�.-.. ..........:t"`�-' ..�..r...-... a..�..:................................ <br />PHONE PHONE <br />................................. <br />PLUMBER WELL DRILLER <br />ADDRESS ADDRESS m O <br />00 <br />o' <br />PHONE PHONE z H <br />DESCRIPTION 4. Sanitary Facilities: ° o <br />1. Work: 2. New Building Details No. Bathrooms I... <br />New Building No. Bedrooms _ ' 0 <br />.......... T e of Construction: D ' <br />Addition Septic Tank Size Gals. ......... f. <br />Sanitary •.••••.•.• Size ...� ... ft. x ...3..Y... ft: ......•••• <br />jj 4a. Absorption Field Site: <br />Filling ......,... Height ..a�..�.rStories....(.... <br />Moving....�� 17Z F1...... Soil Type ................................... <br />Area /f 0 <br />GradinSlope .......................................... <br />Mobile Home.......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... ; <br />Privy.......... home, garage, motel, etc.) Dry Well <br />Well Seepage Trench r <br />Privy .......... <br />Seepage Bed <br />Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road 0' <br />setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- _0 - <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. H <br />----------------------------------- --- @ <br />5. Lot Size: p Fig.A. 6. ca sono <br />ft. x J.�'.0... ft. — .. (J!J sq. ft. ` ,. ,..�id........ <br />CD <br />ct <br />0 <br />l! CD <br />N <br />_ <br />Lo <br />N ' : <br />r -F <br />1 0 <br />:-n <br />o <br />oID <br />ID <br />:rto <br />Cn �Cnwz <br />c d d <br />m. N <br />1 �! -0 cn < C <br />lL' <br />•� •D ° m <br />�'.. <br />.... ... .rl .. ......o c <br />Sig f 4'g t a e <br />Re ks �.......... 4 ....:' - ')'!. ��'/��........:....... ......... ....... .. .1�.--... CD x <br />CD <br />.... .... .... .... ...... .... /. `^.................................................................................. ; <br />u <br />................... <br />....................................... : <br />Inspection Date ....................................... ................... ' : 0 0 0 cn m <br />Zoning Administrator 100 o 0 0 o cn <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 be made without approval of the Zoning Administrator. <br />SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. / <br />f <br />