1984/08/21 - LAND USE - SUB - Certified Survey Map - 11577 (3)

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Cn Burnett County Office of Zoning Administrator APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use cC Ordinance, Sanitation Code, and with all other applicable County Ordinances and the flaws and regulations of the State of Wisconsin. 3 R/(plC .... CORAE� ease print) or AGENT OWNEv a ............................................................................... ADDRESS ADDRESSCD V 1��,...1-/.......9...,j........................... ADDRESS ADDRESS ...........................................................................I........................:......................................................................... ; PHONE PHONE ................. I.................... .......... ............. ....................... ......... ; PLUMBER WELL DRLLER.. ........................................................................................... ; ADDRESS ADDRESS ........................................................................................................................................... PHONE PHONE Z DESCRIPTION 4. Sanitary Facilities: ° 1. Work: 2. New Building Details No. Bathrooms .......... New Building Type of Construction: No. Bedrooms ......... Addition .......... .................................................... Septic Tank Size Gals. Sanitary .......... Size .............. ft. x .............. ft. .......... Filling/Grading ......•... Height ............. Stories ............... 4a. Absorption Field Site: Moving Area Soil Type .................................... .......................................... Mobile Home .......... Slope .......................................... Privy .......... 3. Use (describe exactly, 1 - family Perc. Rate ................................... Well .......... home, garage, motel, etc.) Dry Well .......... Subdivision ✓Seepage Trench .......... .............................................................. Camping Unit Privy .......... Seepage Bed .......... ---------------------------------------------------------------------- Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. ---------------------------------------------------------------------- 5. Lot Size: Fig. A. 6. Location: ................ ft. x .............. ft.. ............................... sq. ft................................................................................ � �� N n O S CD Z _ o Lo CD N r -a c co Z C c CD CD Q m o f 'p• CTI <• y ,� c Z O O a o a Uao _:� ?� O ............................................................................................ s c Signature of Owner or Agent Date — X 70 Remarks......................................................................................................................................................................... m kV p m ........................................................................................................................................................................................ ....................... . Inspection Date ....................................... %lT� ... .......... q . P . v o n m Zoning Administrator `C✓ ° 0 0 0 0 0 o N NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to this application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- with is found to exist. Changes in plans or specifications shall not be made without approval of the Zoning Administrator. SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED.