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Burnett County Office of Zoning Administrator Cn v _ o 0 <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 < y o <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use CD <br /> - <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. a <br /> Q <br /> aF. .fL.T............. ....k ..l.T.. .................................. ............................................................................................ N <br /> JyR (please int) CONTRACTOR or SURVEYOR or AGENT CD <br /> .:�....... �s ! .�J..................................... Q <br /> ADDRESSCD <br /> ADDRESS °+ <br /> ADDRESS ADDRESS :v <br /> P....HO..NE..................................................................................... <br /> PHONE <br /> ........................................................................... ...W.E.......DRI......L........................................................................... <br /> PLUMBER LL LER <br /> h <br /> ........................................................................................ <br /> ......................................................................................... <br /> ADDRESS AD.. DRESS CD <br /> 0 O <br /> PHONE PHONE z y <br /> DESCRIPTION r <br /> 4. Sanitary Facilities: ° o ° ' <br /> 1. Work: No. Bathrooms .. �' ° <br /> 2. New Building Details <br /> o <br /> New Building No. Bedrooms .....i c <br /> ......... Type of Construction: CD <br /> Addition Septic Tank Size Gals. .......... `• <br /> .......... : <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... <br /> Filling .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving ..... .... Area .......... Soil Type .................................... a ; r— <br /> o <br /> Grading Slope .......................................... �« ; <br /> .......... <br /> Mobile Home Perc. Rate ................................... <br /> 3. Use (describe exactly, 1 family <br /> Privy ....„••.. ye,garage, mot I, etc.) Dry Well ....... 1 <br /> Well Seepage Trench .......... <br /> Subdivision d Privy <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 s <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- I a <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 /> a p' <br /> --- ------ ---------------- ----------------------------------- <br /> 5. Lot Size: Fig A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... <br /> CD <br /> N o <br /> o <br /> \ cn <br /> 0 <br /> m <br /> M <br /> A C° <br /> m <br /> A • <br /> V /�o CD C ° (D CD <br /> //+ <br /> _ _. <br /> LD °- D < — <br /> 7v 0 o0 o ID <br /> o <br /> 0 <br /> �o <br /> o <br /> Signature of Owner or Agent Date rt C <br /> X <br /> Remarks -n c m <br /> m <br /> ........................................................................................................................................................................................ ; <br /> ......................................................................................................... _,............................. :u <br /> 0 0 0 0 <br /> Inspection Date ....................................... .. . ................. ...g.:.. ........ ......... M <br /> Zonin Admi strator 0 0 0 0 0 0 (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 />