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L U <br />Burnett County Office of Zoning Administrator--iW CD o <br />t APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT. ►_, <br />0 <br />TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < y N <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 <br />a , O <br />........................................................................................................................ m <br />OWNER (.:please print) CONTRACTOR or SURVEYOR or AGENT CDtP v <br />. .............................................................................. <br />............................................................................ <br />ADDRESS ADDRESS <br />.tr..ti...�1.�.t.�...........�.......5 ............. <br />........................................................................... �^ <br />AD RESP ADDRESS <br />.LA.................... <br />PHONE PHONE • <br />.......... - � ... .............................. <br />PLUMBER /' WELL DRILLER _ <br />.e.Y�..S.f...................................................1 0 <br />........................................................................................... <br />ADDRESS ADDRESS /�CD <br />`^ 0 0 <br />- <br />�o o <br />............. ................................................... <br />PHONE PHONE z H `S' <br />DESCRIPTION 4. Sanitary Facilities: / ° o ° '� <br />1. Work: No. Bathrooms .... 0 <br />2. New Building Details •� :t%i o <br />New Building Type of Construction: <br />No. Bedrooms <br />Addition Septic Tank Size Gals. 7�. <br />............................................................ <br />Sanitary j�'•,,, Size .............. ft. x .............. ft. <br />Filling Height ............. Stories ............... 4a. Absorption Field Site: <br />g Soil Type ...... ............................ r <br />Moven Area ........................................... <br />9 -�•� <br />Gradin Slope .......n�.....0 .......... <br />Mobile Home 3. Use (describe exact) 1 - famil Perc. Rate ......... 7.'..3............... J <br />Privy home, garage, motel, etc.) Dry Well ..........� <br />Well Seepage Trench .......... <br />Subdivision Privy .......... 6� <br />Seepage Bed <br />----------------------------------------------------------------------! W, <br />Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road S 4 + CO; <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 y• <br />STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. p' <br />---------------------------------------- ------------------ : <br />5. Lot Size: Fig. A. 6. Location: a a. <br />r: <br />................ ft. x .............. ft. — ............................... sq. ft............................................................................. <br />N <br />CD <br />N O <br />O <br />N :V! <br />0 <br />0 <br />La <br />trl CD <br />i <br />CD Nr� coZ <br />T. Nao_< — +off <br />'a Ln < C . n' m <br />Z 0 3 CD m <br />6q <br />cn Cn —i <br />�W o <br />o <br />.................. ............... ............................. ... � �..:. <br />Signature of Owner or Agent Date <br />Remarks. .... "'................................................................................................................. CD i m <br />CD <br />.n....................................................................................................................................................................CD <br />: <br />n <br />LA <br />N TI <br />Inspection Date .....�.: • • 0 0 0 o cn m <br />l�. ^�.1.............................................g............................................. : P: o00 oom <br />Zoning Administrator coo 000 <br />VOTE: A Xreliminary 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 />Nith 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 />