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('" 1. (_C -! '. '�/ <br /> Burnett County Office of Zoning Administrator 0 f o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3. <br /> ° v <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use A i� <br /> Ordinance, Sanitation/lC000dde, and with all <br /> pother applicable County Ordinances andthelaws and rrreeguulaattioonns,oef,thhe State of Wisconsin. 3 d �J <br /> .............................. �1. . ......... ...!^ ..1""71. "V O <br /> /// ti <br /> 0 <br /> v <br /> .. m <br /> OWNER (please print) CONTRACTOR or SURVEYOR o AGENT a <br /> Wig... .. <br /> ...... .... ............. . ................ <br /> ADDRESS ADDRESS ^ <br /> ........................................................................................... . . ........................................................................................ <br /> ADDRESS ADDRESS <br /> ........................................................................................... .PHONE.......................................................................................... <br /> PHONE <br /> ............ <br /> ............................................................................ <br /> �l <br /> PLUMBER WELL DRILLER <br /> . . .. . . . . . . . . ...... <br /> . ................................................ <br /> A.DDR ..................... .... .... ..... ...... ........ ......... ..... .. .. A.D...D.R .. . ........... .... ...... <br /> O <br /> o <br /> ............. <br /> .................. <br /> . ..................................................................:.......... o <br /> 0 <br /> PHONE PHONE H <br /> r <br /> DESCRIPTION 4. Sanitary Facilities: o o o <br /> 1. Work: - 2. New Buildin Details No. Bathrooms .......... <br /> New Building .......... Type of Construction: No. Bedrooms .......... <br /> Addition Septic Tank Size Gals. .......... <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... <br /> FillingiGrading .......... Height............. Stories ............... 4a. Absorption Field Site: i <br /> Moving .. Area ........................................... Soil Type .................................... r. <br /> o <br /> Mobile HomeSlope ^ <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Well .......... home,garage, motel, etc.) Dry Well .......... <br /> subdivisionSeepage Trench .......... <br /> .�... .............................I.................... <br /> Camping Unit 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 Q <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 un <br /> g a <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. 0 <br /> _--__---_ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... <br /> C ^ <br /> per, N O <br /> Z <br /> t- <br /> N <br /> -a :E n m Z <br /> c m m e m <br /> W m <br /> Z O o n 31 <br /> N m m <br /> ........................................................................... <br /> ...�.�..7..:.. ........ E� o [ [ C <br /> Signature of Owner or Agent Date <br /> X <br /> Remarks ......................................................................................................................................................................... p <br /> ............................................... �� k : T <br /> M m <br /> Inspection Date ....................................... .C�i??yL(j. ... ... . ..................... ' �. <br /> 0 o r N <br /> Zoning Adm' istrator '" 8 8 8 8 8 8 in <br /> NOTE: A preliminary site inspection must be made and site approval granted on all struci 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 Administratot. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />