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<br /> Burnett County Office of Zoning Administrator 0 7 0 0
<br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 c
<br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as '� _ :C"\
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<br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use C '
<br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 Q
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<br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT a
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<br /> ADD ESS ADDRESS i
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<br /> ADDRESS ADDRESS
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<br /> PHONE PHONE
<br /> PLUMBER WELL DRILLER
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<br /> ADDRESS ADDRESS m L)
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<br /> PHONE PHONE Z H r
<br /> DESCRIPTION 4. Sanitary Facilities: ° o °
<br /> No. Bathrooms v
<br /> 1. Work: 2. New Building Details "'•' :� o '
<br /> New Building .......... Type of Construction: No. Bedrooms ....�1..`... :� a
<br /> Addition .....,.... ....................................................
<br /> Septic Tank Size Gals. cF� ;.0
<br /> Sanitary `�- Size .............. ft. x .............. ft. .......... ?�
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<br /> Filling .......... Height............. Stories ............... 4a. Absorption Field Site:
<br /> Moving .......... AreaSoil Type .......�'l.�1vo............. r
<br /> ...........................................
<br /> Grading Slope ........ ..Q............................ o
<br /> .......... Perc. Rate ...............� i i
<br /> Mobile Home .......... 3. Use (describe exactly, 1 -family "'•' " • •' •'•' '
<br /> Privy .......... home,garage, motel, etc.) Dry Well ..........
<br /> WellSeepage Trench ..........
<br /> Subdivision .......... .................................................... Privy ..
<br /> ........
<br /> .......... ....................................................
<br /> Seepage Bed ..........
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<br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc.,should be sketched in Fig. A. Include road 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-
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<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.
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<br /> 5. Lot Size: Fig. A. 6. Location:
<br /> ................ ft. x .............. ft. . ............................... sq. ft. ...............................................................................
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<br /> Signature of Owner or Agent Date C
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<br /> Remarks ......................................................................................................................................................................... m 0
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<br /> Inspection Date ps- _. ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, ;'�' 0 0 0 0 o un m
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<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.
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