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i <br /> Burnett County Office of Zoning Administrator v o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT rf B <br /> QTO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as O <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land UseCDc <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 Q G <br /> Q <br /> ..1.{'.. .......... .V.. l..!`h! .tt2.. 1........................... ............................................................................................ Cc: m O <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT co <br /> Q <br /> ............ �I..1..,................................ <br /> ADDRESS ADDRESS + .� <br /> kR � <br /> ...............-......................................... x� <br /> ADDRESS AD�'c��• � - � � '� <br /> PH E PHONE <br /> .. . .� ..�...... ................................................ ......... �........... <br /> PLUMBER WELL DRILLER <br /> .............. <br /> ADDRESS............................................................................ ADDRESS '1 <br /> 0 <br /> ............................................................................. <br /> �. o PHONE PHONE <br /> :3z r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms <br /> o <br /> New Building Type of Construction: No. Bedrooms .......... <br /> Addition Septic Tank $ize Gals. ...... ... <br /> Sanitary ,,,,, Size .............. ft. x ft..... ........ <br /> 4a. Absorption Field Sit V <br /> Filling/Grading .......... Height............. Stories ............... p <br /> Moving .......... Area ................................... Soil Type .................................... <br /> ........ <br /> • o <br /> Mobile Home Slope .......................................... <br /> Privy .......... 3. Use (describe exactly, 1 -family <br /> Perc. Rate ................................... `> >" ;c <br /> Well „ , „ home,garage, motel, etc.) Dry Well .......... <br /> .. . . <br /> Subdivision Seepage Trench .......... , <br /> Camping Unit Privy , <br /> �} <br /> Seepage Bed OL . <br /> ——————————————————————————————————————————————————————————— -- Cn <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. 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 <br /> 5. Lot Size: Fig. A. 6. Location: ` <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... CD <br /> 9 <br /> N O <br /> O 7 <br /> o ,/1 <br /> o :G <br /> 0 <br /> 0 <br /> z <br /> 0 <br /> co <br /> 114 <br /> M CD C r T P <br /> [fia < rDf <br /> CD N CD <br /> Q < CC)Ul < yCC <br /> CD m <br /> Z o o a 7p <br /> O > a <br /> UT o <br /> 11\ o <br /> . ..... ... ....... .................................... ...................................... <br /> SI V.-re-of O er or Agent Date — <br /> /�5) / X <br /> Remarks .1:.�:'.. 1. 4?.. �!?" ................................................................................................................... -n m <br /> ........... m <br /> Co <br /> ............ .............................................................................................................................. — <br /> :.T... ................................... . ........................................................................... . . . . . . <br /> Inspection Date ..../ . ................ ?✓" .... ............... ........ ................. . . . " m <br /> ocNi oho <br /> Zoning Adminis rator o 0 0 0 0 o y <br /> NOTE: A preliminary site inspection must he 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 />