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Burnett County Office of Zoning Administrator 0) CD o 0 <br />APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT3 <br />m o <br />TO THO-6+i1L")L-..ApM�1STRATOR. The undersigned hereby makes application for a Permit for the work described and located as <br />shown herein. The undersig,ied agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m :� <br />Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 <br />Q%a'?.. .. ......� - ............ ....................... ... .... .............................. - \ <br />o <br />OWNER (please print) CONTRACTO or SURVEYOR or AGENT <br />a <br />.......... . . <br />ADDRE ADDRESS <br />CD <br />ADDRE'^,t�%..!••.'..�1.%....................................................................................................................... <br />.,� ADDRESS <br />....................................................................................................................................................................................... �v <br />PHONE PHONE <br />............................ <br />PLUM �� WELL DRILLER <br />` . 2......... <br />ADDRESS ADDRESS :.� m o <br />�......4�........$............................................................................................................. Z o <br />O <br />PHNE PHONE y <br />DESCRIPTION 4. Sanitary Facilities: V o ° <br />1. Work: No. Bathrooms <br />2. New Building Details o <br />New Building No. Bedrooms ... .. oQ <br />.......... Type of Construction:CD <br />Addition � Tank Size Gals. .......... <br />San' "�...s. Size ft. x ft. <br />Q <br />Fillip /Gradin 4a. Absorpt Field Sie: <br />Filling/Grading Height ............. Stories ............... n <br />Moving oil Type ...............•.................... <br />.......... r <br />Slope ........................................ Y o <br />Mobile Home ,,,,,,,,,, •• a <br />Privy .......... 3. Use (describe exactly, 1 - family Perc. Rate ................................... F <br />Well ........., home, garage, motel, etc.) Dry Well """"" <br />Subdivision Seepage Trench ........ <br />4 :\ <br />Camping Unit .......... <br />Privy �t <br />................................................ <br />Seepage Bed ......... ,r� <br />---------------------------------------------------------------------- I n�1`�. <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- `� Q <br />section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING A <br />STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. f p' <br />----------------------------------------------------------------- d <br />5. Lot Size: Fig. A. 6. Location: kl� <br />................ft. x ft. s ft. <br />-'% <br />n <br />CD <br />O 7 <br />7 <br />�o <br />cnr= �� T'Z <br />CD C -. <br />Q CLC <br />CD Z 0 0 D a <br />M <br />V0 p <br />........... o C <br />Sig <br />m of Owner or Agent Date — <br />Re®rk �, ........................................................................................................................................................................ m . C <br />CD <br />n <br />........................................................................................................ .................... <br />.N1 Nm <br />InspectionDate ....................................... �1?r!=Q................. .............................. :_ m <br />Zoning Admin strator �� o 0 0 0 o N <br />NOTE: A preliminary site inspection must be made and site approval granted on all structures involvir c�sanitary fac lities <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 huild- <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 />