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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 />a....e.......- <br />e. <br />v`r NOWN R (please print) CONTRACTORorSURVEYORoT <br />....................................................... . <br />ADDRESS ADDRESS <br />....................................................................................................................................................................................... <br />ADDRESS ADDRESS <br />.............................................................................................................................................................................. <br />PHONE PHONE <br />....................................................................................................................................................................................... <br />PLUMBER WELL DRILLER <br />................................................................................................•.....•................................................................................ <br />ADDRESS ADDRESS <br />.................................................................................................•..................................................................................... <br />PHONE PHONE <br />DESCRIPTION <br />4. Sanitary Facilities: <br />1. Work: 2. New Building Details <br />No. Bathrooms .......... <br />New Building .......... Type of Construction: <br />No. Bedrooms .......... <br />Addition .................................................... <br />.......... <br />Septic Tank Size Gals. .......... <br />Sanitary .......... Size .............. ft. x............. ft. <br />......••.. <br />Filling/Grading .......... Height ............. Stories ............... <br />4a. Absorption Field Site: <br />Moving.......... Area ........................................... <br />Mobile Home ... I...... <br />Slope .......................................... <br />Privy .......... 3. Use (describe exactly, 1 - family <br />Perc. Rate ................................... <br />Well home, garage, motel, etc.) <br />Dry Well .......... <br />Subdivision <br />Seepage Trench .......... <br />Camping Unit.......... <br />Privy .......... <br />.................................................... <br />---------------------------------------------------------------------- <br />Seepage Bed .......... <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. <br />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 EXISTING <br />STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br />5. Lot Size: Fig. A. 6. Location: <br />T <br />................ ft. x .............. ft.. ............................... sq. ft..............................................................................., <br />C s2 <br />a y <br />1 I rrdjj <br />N <br />O <br />0 <br />CD <br />0 I <br />rv5cnmz <br />y3 � CX = a i <br />U1 ca � � co � <br />0 N' '" a rn <br />0 0 a <br />:moo 7J <br />CD <br />o C <br />Signature of Owner or Agent Date — <br />X <br />Remarks -n ' <br />CD <br />.................................................................................................................................................................................... <br />Inspection Date ....................................... �..� . .....�i��rai�r <br />tp o o o <br />T <br />M <br />M <br />Zoning Ad�� '• o 0 0 0 0 o N <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 />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 />