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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 />fi...C. ..., n...0 s6.. ... <br />........................... ....... ... <br />OWNER (please print) CONTRACTOR ....... .. <br />or SURVEYOR . . . . . . or AGENT .. <br />ADDR ADDRESS <br />+ <br />............... (^ f �'........................................................................................ <br />ADDRESS ADDRESS <br />e...hn e <br />........ ........................ <br />S�n <br />...........................X-3!+............................................................................................ <br />PHONE <br />...". `.�........................... <br />........................................................................................... <br />PLUMBER WELL DRILLER <br />A............................................................................................ADDRE...........S.S .............................................................................. <br />DDRESS <br />...............PHONE..................................................................................... <br />PHONE <br />DESCRIPTION 4. Sanitary Facilities: <br />1. Work: 2. New Building Details No. Bathrooms .......... <br />New Building.... Type of Construction: No. Bedrooms I......... <br />Addition ..�........................................................ Septic Tank Size Gals. .......... <br />Sanitary Size ft f <br />.......... .............. x .............. t. <br />Filling/Grading .......... Height ............. Stories .............1. <br />.......... <br />4a. Absorption Field Site: <br />Moving Area ..................... <br />Soil Type .................................... <br />Mobile Home I........ <br />Slope .......................................... <br />Privy .......... 3. Use (describe exactly, 1 - family <br />Perc. Rate ................................... <br />Well ......... home, garage, motel, etc.) <br />Dry Well .......... <br />Subdivision .......... <br />Seepage Trench .......... <br />Camping Unit .•........ <br />Priv ......•••• <br />---------------------------------------------------------------------- <br />Seepage Bed <br />Location of proposed structures and existing structures well, sewage systems, roads etc., <br />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- <br />section, show the intersecting highways and the setbacks required along them and at the <br />intersection. CLEARLY LABEL EXISTING <br />STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br />---------------------------------- <br />5. Lot Size: Fig. A. 6. Location: <br />................ ft. x .............. ft. — ............................... sq. ft................................................................................ <br />o z <br />3 o <br />0 <br />N � <br />CD N <br />Z � <br />oN <br />CL <br />a � <br />o <br />O \o �( <br />ro G7 <br />n <br />Z <br />'^ r <br />0 0 0 <br />-n <br />o <br />t� <br />i <br />c <br />O_ <br />N p' <br />O <br />••-- <br />c _ :W <br />co <br />O - <br />O <br />7 <br />:t _ <br />-n :W <br />z <br />0 <br />J o <br />:N" <br />[.. v M to r' v (n <br />CD c 0)W c m <br />Q {fly a < – F <br />CD N Q C co <br />U1 < y ,� C <br />z !7 O. D Q <br />11 13 0_3.:CL <br />1 O <br />Signature of 0 er or Agent Date 0 C <br />X <br />Remarks.....................F.%........................................................... m m <br />�LCD <br />° <br />....................................................................................................................................................................................... � <br />........................................................................................................ <br />::: <br />-n <br />nspection Date............N 1 m K) m <br />..........................�° <br />......11 ................... m <br />Zoning A inistrator N o 0 0 0 0 o <br />0 0 0 0 0 0 <br />OTE: 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 />tis application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build - <br />g until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br />ith 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 />