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Burnett County Office of Zoning Administrator <br />3 <br />CD <br />0 <br />0 <br />- APPLIQATION FOR SANITARY — LAND USE — BUILDING PERMIT <br />d �* <br />�• <br />Grading <br />:o <br />TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as <br />m <br />H <br />N <br />o <br />Perc. Rate ................................... <br />shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use <br />the State of Wisconsin. <br />3 <br />a <br />Dry Well .......... <br />S.......... <br />Seepage Trench <br />. <br />Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of <br />.................................................... <br />Privy .......... <br />iv <br />O <br />d4k.040y!Uy..44X .................................. .. ............................... <br />Seepage Bed ....�'' <br />------------------ <br />Location of proposed structures and existing structures, well, sewage systems, roads, etc., <br />- --------- <br />should be sketched in Fig. A. Include road <br />.................y! ....................... <br />OWNER (please print) CONTRACTOR or SURVEYOR or AGENT <br />CDCD <br />Q <br />ADDRESS ADDRESS <br />r.......Lc1, 5, .................................. <br />ADDRESS ADDRESS <br />CD <br />m <br />................. <br />PHONE <br />.4. ..�.........� � -..a <br />PLUMBER <br />%1'z, .. ............ /5! ....... .. ��' . <br />ADDRESS <br />�C'. .,1...'.s.%�? ............................... <br />PHONE <br />DESCRIPTION <br />1. Work: �. <br />New Building .......... <br />Addition .......... <br />Sanitary <br />... <br />PHONE <br />............ u <br />,�/ WELL DRILLER <br />,5!?/ , :gyp p <br />ADDRESS CD 0 <br />...................................................................................................... o <br />PHONE Z H <br />2. New Building Details <br />Type of Construction: <br />...................... ..........,. ,.. <br />Size ..... ft. x ...... ..Q.. ft. <br />4. Sanitary Facilities: <br />No. Bathrooms <br />No. Bedrooms <br />Septic Tank Size Gals. <br />° <br />o <br />:4J <br />Moving <br />O R1 <br />Soil Type ............. !JAIV. <br />r - <br />• o <br />Grading <br />.......... <br />.......... <br />.......... <br />Filling <br />.......... <br />.......... Height ............. Stories ..../.......... <br />4a. Absorption Field Site: <br />i....... <br />Moving <br />Area ............... <br />Soil Type ............. !JAIV. <br />r - <br />• o <br />Grading <br />.......... <br />.......... <br />Slope ....................0......... . <br />Mobile Home.......... <br />3. Use (describe exactly, 1 -family <br />Perc. Rate ................................... <br />Privy <br />Well <br />home, gars mote4 tc.) <br />... � ....�.... .. .......... ..... <br />Dry Well .......... <br />S.......... <br />Seepage Trench <br />. <br />Subdivision..........C <br />.................................................... <br />Privy .......... <br />Seepage Bed ....�'' <br />------------------ <br />Location of proposed structures and existing structures, well, sewage systems, roads, etc., <br />- --------- <br />should be sketched in Fig. A. Include road <br />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- Ld <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 />---------------------------------------------------------------------- n <br />5. Lot Size: 70 Fig. A. n <br />................ ft. x .............. ft. — ............................... sq. ft. <br />., �..... 4A./ ............. ......-a .................... <br />Signature of Owner. or, gent Date <br />�, <br />Remarks ..refiling.,must be at least 75 feet from the normal highwater mark of lake. <br />................................................................ <br />Well must be at least 50 feet from drainfield. <br />Inspection Date ....................................... <br />..................................................................................... <br />Zoning Administrate <br />10 <br />:rl <br />�N <br />n <br />U) <br />CO <br />0 <br />N O' <br />o <br />:3 :W <br />N <br />h <br />-n <br />CD :Q <br />Z <br />o <br />CD <br />m <br />CD <br />0 c N c <br />NQQ< <br />a �, < m _ M <br />rF O N <br />Z O p <br />O 3 <br />�C C p <br />:v o C_ <br />m x m <br />CD <br />e <br />T <br />o o 0 <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 he made without approval of the Zoning AdministratQ;r,;, <br />SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVECIr— <br />w <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 he made without approval of the Zoning AdministratQ;r,;, <br />SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVECIr— <br />w <br />