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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 />So rQ...C?��A�..��XI.ACQ1jS'�- ............................ <br />............................................................ .......... <br />OWNER (please print) CONTRACTOR or SURVEYOR or AGENT <br />................................................W..WL.S.C................................................. <br />ADDRESS ADDRESS <br />...................................................................................................................................................... <br />ADDRESS ADDRESS <br />PHONE PHONE <br />......................................................................................................................................................... <br />PLUMBER WELL DRILLER <br />................................. <br />ADDRESS <br />ADDRESS <br />; <br />................................................................................ <br />PHONE <br />PHON.......E........ ................... <br />....................................................... <br />Z <br />DESCRIPTION <br />4. Sanitary Facilities: <br />° <br />1. Work: <br />2. New Building Details <br />No. Bathrooms <br />New BuildingType <br />of Construction: <br />No. Bedrooms .......... <br />AdditionSeptic <br />Tank Size Gals. .......... <br />Sanitary .......... <br />Size .............. ft. x ft. <br />......•••• <br />Filling/Grading <br />Height Stories <br />g <br />4a. Absorption Field Site: <br />Moving ... I...... <br />Area ........................................... <br />Soil Type .................................... <br />Mobile Home <br />Slope .......................................... <br />_. <br />Priv <br />Privy .......... <br />3. Use (describe exactly, 1 -family <br />Perc. Rate ................................... <br />Well ....,.., , <br />home, garage, motel, etc.) <br />Dry Well .......... <br />y <br />Subdivision. <br />Seepage Trench .......... <br />�J <br />CampingUnit .......... <br />Privy .......... <br />.................................................... <br />See -a e Bed <br />CD o z <br />3 <br />C <br />o_ <br />Q o <br />m <br />L <br />a z <br />'� z <br />f <br />CD <br />0 0 <br />o' <br />o <br />-o <br />0 <br />0 <br />P <br />g .......... <br />___ : <br />71 <br />Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road JJ C <br />setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- i o- <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. ] 0 <br />o <br />-------------------------------------- �I <br />---------------------- <br />5. Lot Size: <br />Fig A. 6. Location: <br />xi :fv <br />................ ft. x ft. s ft. -> <br />— q....................................................................... <br />rn <br />CD <br />0 <br />PtA1L^� GS Nl o <br />p :y <br />4 rt <br />Z 0 <br />0 <br />:0 <br />-o <br />NT <br />:L z <br />0 <br />cn <br />:f <br />M Cl) rym op <br />C 41 2. C CD <br />0 Q a < CD 7 a F <br />'O ca <br />Cil G N ra <br />Z oo.�" m <br />Da <br />o Z am 3 <br />ir <br />.......... . ��...........�.. ......... ..... C <br />Signature of OwneDateX ...... <br />Remarks................................................................................................................................................. _ : : : : : : 0M <br />................................................................................................................................ ©IW m <br />o P �, <br />InspectionDate ....................................... ".......................................................... p: f. o ' o � o N <br />Zonin Administrator 4 0 0 0 0 <br />JOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitar <br />efore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must ` <br />his application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing <br />rig until a permit has been issued. A permit may be revoked if misrepresentation of any of the inform <br />with is found to exist. Changes in plans or specifications shall not be made without approval of r <br />SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFIC <br />