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Burnett County Office of Zoning Administrator �' c <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT ; 3 j, <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 0 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> regu�a ionsof theS to of Wisconsin. .. ........... <br /> .... YlY �.! ^ I. �....................... . . . . . . . ................................................ ......... $ <br /> m <br /> OWNER lease print) n CONTRACTOR or SURVEYOR or AGENT S <br /> 5Lte!PE.....N — '• s <br /> ADDR S ADDRESS <br /> ADDRESS <br /> l <br /> ...i.w ................-:>..::......................... ........................................................................ <br /> ADDRESS .................... <br /> .......... <br /> ................................................................................ .................................................................................. <br /> �....,�....�1/. <br /> . ./�7..1. / Z PHONE <br /> PLUMBER ��� WELL DRILLERlX+' i <br /> �........��/PBi1(/} /////.j . .......... ............................................................................... O - :�• <br /> ADDRESS ADDRESS n <br /> 7� s 694 ................................................ 0 <br /> ......................................... ............................................ 0 <br /> PHONE PHONE Z J r <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> 1. Work: 2. New BuildingDetails 's, o i <br /> New Building „-„••... Type of ConNo. Bathrooms "”""" <br /> Construction: No. Bedrooms .......... :--7 <br /> —' <br /> Addition .................................................... Septic Tank Size Gals. .......... <br /> Sanitary .�•.... Size .............. ft. X .............. ft. .......... yr <br /> Filling/Grading Height............. Stories ............... 4a. Absorption Field Site: 1 . <br /> Moving .......... AreaSoil Type .................................... ' o <br /> ........................... ............... <br /> Mobile Home Slope ....................................... y <br /> ... <br /> .......... Y .~ <br /> Privy .......... 3. Use (describe -family Perc. Rate ................................... i <br /> Wall Dry Well 1 i <br /> ,,,.,...., home,garage, motel,etc. <br /> Subdivision <br /> Seepage Trench o ' <br /> .......... """"" <br /> Camping Unit Privy .......... <br /> OCh.... (1u _ �jZV(C �Lg Seepage Bed ......... j <br /> Location of proposed structures and existing structu�_well, sewage systems, roads, etc., should be sketched in Fig. A. :W c <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. `„— <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> _______________________________________ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... <br /> i <br /> N O <br /> O J <br /> f <br /> k4 <br /> 0 <br /> 7) i J <br /> I T W <br /> — Z �A <br /> O <br /> 71 <br /> d <br /> J <br /> b <br /> N <br /> a .Nvcnr Dmm <br /> ON O b m <br /> O i»O '2 D � <br /> NJ Nd � <br /> J0 20 m <br /> o <br /> � � J O <br /> to � <br /> f C—A <br /> nrC ...... .. ......... .. ............. .....��7 o <br /> In <br /> Si ature of Owner or.Agent Dat o <br /> �UP pd C� ztom—. <br /> Remarks .. <br /> y . <br /> 0 <br /> Z .:.... .:. ,lJ.�.{...+.2...........y..............�.�.;/l�....l...W..(.�...-'.../....4.e..�.r... <br /> .. ..................................................................................................... ........... <br /> mmInspecoon Date o <br /> Zoning Administrator 8 $ g N <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this application before a permit will <br /> be issued. Do not purchase or install a septic tank, do any plumbing or start any building until a permit has been issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />