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Burnett County Office of Zoning Administrator W CD 0 0 <br />APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT. <br />0 <br />TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < H ?� <br />shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use :o C: : Q <br />Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. a :C <br />N <br />Ti•••• •• T+�. X..J.: •..... �rA :: ••••••••••••••..•••••• (D <br />OWN R (please print) CONTRACTOR or SURVEYOR or Ar A E� a <br />a <br />ADDRESS ADDRESS <br />ADDRESS ADDRESS <br />PHONE PHONE <br />.................................................................. `) <br />PLUMBER WELL DRILLER r <br />................................................................................................................................................................ <br />ADDRESS ADDRESS C o <br />.................................................................................................................................................................................... O <br />PHONE PHONE z H r <br />DESCRIPTION 4. Sanitary Facilities: o <br />1. Work: 2. New Building Details No. Bathrooms z <br />New Building •......... Type of Construction: <br />No. Bedrooms <br />Septic Tank Size Gals. <br />Addition '� <br />.............................................................. <br />Sanitary ••..•.•••• Size ft. x ft. """"" <br />Filling/Grading Height Stories <br />.............. <br />4a. Absorption Field Site: <br />Moving Area Soil Type .................................... o <br />........................................... Slope <br />Mobile Home .................................... <br />......... <br />Privy .......... 3. Use (describe exactly, 1 . family Perc. Rate ................................... <br />Well home, garage, motel, etc.) Dry Well <br />Subdivision Seepage Trench .......... <br />........................................................ <br />Camping Unit Privy <br />Seepage Bed .......... <br />---------------------------------------------------------------------- cn <br />Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road Q <br />setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- fl <br />section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING ,<—„• <br />A <br />STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. 0 <br />------------------ <br />5. Lot Size: Fig. A. 6. Location: <br />................ ft. x .............. ft. — ............................... sq. ft................................................................................ <br />N <br />s �s�CD <br />Iii I N o <br />1 I o <br />1 <br />svy <br />I �. <br />' v, <br />z <br />o <br />Lo <br />CD <br />D <br />r T to W 2 <br />C 7 1• N 7 C fD <br />0Z <br />io m a M <br />Z 00: a <br />oam <br />Z .' <br />�l".3/ may......... :w0 c <br />..... ........ .... ..... . <br />Signature of Owner or Agent Date '* ; : . ; . • <br />X 70 <br />Remarks T' <br />. . : . . . <br />CD <br />........................................................................................................................................................................................ <br />........................................................................................................................................................ti ........................... <br />Inspection Date ....................................... ..�.. .............. ............M J............. :10 0 0 0 0 o rn <br />0 <br />Zoning Admi istrator S o 0 cc o N <br />NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <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 build- <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 />