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V <br />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 />,� a <br />................................................................ <br />.................................................................. ........... <br />OWNER (please nt) 7 CONTRALTO Ior SURVEYOR or AGENT <br />((-/� <br />ADDRESS ADDRESS <br />0.,?( �7C6 <br />ADDRESS c <br />(sem..... yJ / '7 <br />Z ADDRESS <br />.................. .. <br />................................................................ <br />PHONE PHONE..... <br />........................................................................................... <br />PLUMBER.WELL .........D..R..I...LL.... <br />E..R .................................................................... <br />ADDRESS <br />ADDRESS <br />...................................................................................... <br />PHONE <br />............................................................................................ <br />PHONE <br />DESCRIPTION <br />4. Sanitary Facilities: <br />1. Work: <br />2. New Building Details <br />No. Bathrooms .......... <br />New Building <br />Type o Construction: <br />No. Bedrooms <br />Addition <br />x ......, X;w-A. <br />Septic Tank Size Gals. .......... <br />Sanitary.......... <br />Size ...../..d.... ft. x ....� �.... ft. <br />Filling/Grading <br />......•... Height .....g..... Stories .....L........ <br />4a. Absorption Field Site: <br />Moving.......... <br />Area ........................................... <br />Soil Type .................................... <br />Mobile Home <br />.......... <br />Slope .......................................... <br />Privy <br />.......... 3. Use (describe exactly, 1 - family <br />Perc. Rate ................................... <br />Well <br />Subdivision <br />.......... home, garage, Wei, e .) <br />Dry Well .......... <br />Seepage Trench .......... <br />Camping Unit <br />Privy .......... <br />....... <br />Seepage Bed <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 <br />and location and setback from all bodies of water. <br />If property is located at a highway inter- <br />section, show the intersecting highways <br />and the setbacks required along them and at the intersection. <br />CLEARLY LABEL EXISTING <br />STRUCTURES AND PROPOSED <br />STRUCTURES AND ADDITIONS. <br />5. Lot Size: <br />------------------ <br />Fig. A. 6. Location: <br />--------- <br />................ ft. x .............. <br />ft. — ............................... sq. ft................................................................................ <br />Ste- /a'111� /" S <br />O,vkj.co &" <br />0) CD 0 z <br />1 o <br />0 U <br />C <br />Q <br />3 a O <br />H � <br />C <br />CD CD <br />a <br />d <br />m <br />�N <br />Cn 0 <br />0 o <br />0 r: <br />Z <br />0 0 0 <br />v <br />o <br />h <br />0 <br />n <br />N <br />0 <br />0 <br />110, <br />Cnr _0Cn co Z <br />n 00) M w <br />-D <m E• i <br />Co N Q C c— W a rL <br />MZ 00 D a <br />0 0 ac <br />.. ...... ...........Sl .y.. � <br />Signature of Owner or en t Date <br />Remarks.. GGA.........................................................................../...................................... to 0 <br />CD <br />................................ ........t�...li.`�..................................... O . : . . . <br />........................................................................................................... A...........�qA <br />. . . . . <br />Inspection Date ....................................... ? .... .. ........ ............................ : \` o c°Dn o m <br />Zonidmini trator ��J o 0 0 o W <br />DOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanit facilit cs <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 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 />