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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 />.............. ....... .. .�(6. <br />OWNE (print) CO TRACTOR or SURVEYOR o A <br />C20 <br />,...1!1.......5 y <br />ADDRESS ADDRESS <br />........ '.............................. <br />ADDRESS <br />PHONE.................................. <br />............................ .......................... <br />ADDRESS <br />............................... .PHON.E............................................................................. <br />........................................................................................... <br />PLUMBER <br />.......................................................................................... <br />WELL DRILLER <br />........................................................................................... <br />ADDRESS <br />.......................................................................................... <br />ADDRESS <br />PHONE <br />......................................................................................... <br />PHONE <br />DESCRIPTION <br />1. Work: <br />New Building <br />Addition <br />Sanitary <br />Filling/Grading <br />Moving <br />Mobile Home <br />Privy <br />Well <br />2. New Building Details <br />.......... Type of Construction: <br />.......... .................................................... <br />.......... Size .............. ft. x .............. ft. <br />.......... Height ............. Stories ............... <br />.......... Area ........................................... <br />.......... 3. Use (describe exactly, 1 - family <br />•,........ home garage, motel, etc.) <br />4. Sanitary Facilities: <br />No. Bathrooms ......... <br />No. Bedrooms ......... <br />Septic Tank Size Gals. ......... <br />4a. Absorption Field Site: <br />SoilType ................................... <br />Slope......................................... <br />Perc. Rate .................................. <br />Dry Well ......... <br />Seepage Trench <br />z <br />d 0 0 <br />3 <br />= 0 <br />N <br />3 CL <br />V <br />o- O <br />m <br />CL <br />m <br />�o <br />:X <br />+ 0 <br />c <br />Z N r <br />0 0 0 <br />' F � <br />V <br />X <br />• ski r <br />0 <br />Ry .+ <br />'V <br />Subdivision.......... <br />.............................................................. <br />Camping Unit..........Privy .......... <br />.................................................... <br />Seepage Bed .......... <br />---------------------------------------------------------------------- <br />Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road N <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 intersection. CLEARLY LABEL EXISTINGj.b- G <br />STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. ,kW1+, <br />---------------------------------------------------------------------� Ce, O <br />5. Lot Size: Fig. A. 6. Location: <br />................ ft. x ft. sq. ft. <br />Cn <br />c <br />H <br />0 <br />N <br />0 <br />c <br />0 <br />ANN <br />:O c T <br />CD <br />0 <br />a <br />r <br />C <br />0 <br />S <br />0 <br />_3 <br />M cn 0 C ao z <br />C <br />CD 0- <br />N m W m <br />Z a <br />_ <br />to <br />Signature of Owner or Agent Date <br />X <br />Remarks T: : . . : . : m <br />on <br />......................................................................................................................................::..:.. -n <br />InspectionDate.......................................m..�.....o...W............... P <br />rt ✓ 0Zoning ist <br />y <br />VOTE: 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 />,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 />