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Burnett County Office of Zoning Administrator �' c
<br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT0 W
<br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and W
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<br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the n
<br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and
<br /> regulations of the State of Wis onset. 3, a
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<br /> OWNIER4please print)
<br /> .... .SU..R..VE.. Y. .....OR.....or....A..G.......................
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<br /> � CONTRACTOR or ENT �--
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<br /> ADDRESSADDRESS............................................................................
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<br /> ADDRESS ADDRESS
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<br /> PHONEPHONE
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<br /> PLUMBER WELL DRILLE.... .... R
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<br /> PHONE PHONE Z « r A
<br /> DESCRIPTION 4. SanitaryFacilities: ° ii o '
<br /> 1. Work: No. Bathrooms
<br /> 2. New Building Details """'.•' �o ;m
<br /> New Building ,,,,,,,,,, Type of nstr coon: \ No. Bedrooms
<br /> Addition ,,,,,,,,,, „(,})O0.11.,,,, t; ,K„/ ,,,,,,, Septic Tank Size Gals. .......... : ��
<br /> Sanitary .......... Size .....y.. ft. x ....q./..k ft. ..........
<br /> Filling/Grading .......... Height...7...2.. Stories ..../.......... 4a. Absorption Field Site: i T'i rJ
<br /> Moving ......... Area ......................................... Soil Type ....................................
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<br /> Mobile Home Slope ........................
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<br /> Privy ..L� 3. Use (describe exactly,'1 -family Perc. Rate ...................................
<br /> Well .......... home fgaryge, motel,etc.) Dry Well ....... .. 2
<br /> Subdivision I Seepage Trench .... o
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<br /> Camping Unit .......... Privy . .....
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<br /> Seepage Bed ..........
<br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A.
<br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at :g�Q
<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. :1 ;p\`
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<br /> 5. Lot Size: /p)c�a�� Fig. A. 6. Location: �
<br /> ..L.QQ...... ft. x .. ...... .... ft. — ...af....,/..../. Q........ sq.ft. S:
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<br /> Signature of Owner or Agent � Date � o
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<br /> Inspection Date ....................................... ..... .......... . .. . ... ...................... v' Ut O O N m
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<br /> Zoning dministrator g g o o g Cn
<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.
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