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I <br /> Burnett'County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT m 3 <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and q � <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the n i <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws nd 3 <br /> regulat' ns of the Stateo�is,c.\o^nsin. .: a <br /> h k J l.`.i O.Sj...Q'ar.......c.rQ`J )e-)..................... ..... r n <br /> ......... . <br /> ............................... <br /> 32) <br /> R Iple Drmt) DO RACTOR or SURVEYOR or AG NT <br /> .1..,... QX. . . ..................................... .... (.d�La�id,C L .....�`�... . : ..... d <br /> ADDRtySSry1 ADDRESS ?lam <br /> ...r�..1/.l..U .�..�. .... .. ...................... ..................................................................................... ...... ;�� 1 <br /> ADDRESS �• •- ADDRESS <br /> ........................................................................................... ..................................................................................... ...... <br /> PHONE PHONE <br /> ........................................................................................... 'W"'E...LL....D..RIL.. L........ER.............................................................. ...... <br /> PLUMBER W <br /> O <br /> ADDRESS ADDRESSn o <br /> ........................................................................................... ..................................................................................... ...... o' 11 <br /> PHONE PHONE Z <br /> DESCRIPTION 4. Sanitary Facilities: ° c <br /> 1. Work: 2. New Building No. Bathrooms ...... c <br /> New Building No. Bedrooms <br /> .......... TYPe of Construction: .•' •'•"' <br /> Septic Tank Size Gals. <br /> Addition .......... .................................................... < <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... <br /> Filling(Grading .......... Height............. Stories ............... 4a. Absorption Field Site: i <br /> Moving .......... Area ...................... Soil Type ............................ ....... <br /> .................. c i <br /> MobileHome Slope .................................. ....... <br /> .......... <br /> Privy .......... 3. Use (describe exactly,'1 -family Perc. Rate ........................... ....... m <br /> n <br /> Dry Well m <br /> Well ,,,1 home,garage, motel,etc.) Seepage Trench o <br /> Subdivision r�"('� " """' ' <br /> ... ... .............. ..................................... <br /> Camping UnitPrivy .. ....... .d r <br /> .......... .................................................... IN . <br /> Seepage Bed .. ....... <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fill, A. F <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is local d 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. ............................................................................... i <br /> "i U O <br /> 0 J <br /> Ra--L '�r � o <br /> O <br /> JJ Z <br /> C1 c> <br /> � 1 <br /> m c . N m 0 Mai <br /> a a <br /> n v JJO - - m <br /> any <br /> 9 < a d C y J J 3 <br /> 0 0 �0 <br /> O A G D ' <br /> mn <br /> n O p <br /> +' Y <br /> o—U A — <br /> Sig <br /> �f........ ..................... <br /> C <br /> A <br /> M <br /> Si n re of O ner o ent Date /�'•++�� <br /> Remarks <br /> N <br /> ......................................................................................................... .... ................... ... ....`UD..................L <br /> ..... ..... V�\ : 8 : <br /> Inspection Date /y��� Y'I�/y�/�J , N Ol N N m <br /> pE ....................................... ... ..:J3•W.4Ll... ...:......!ll..��\M"M.� ...... .... O, W N O O N m <br /> Zoning Administ or 888 8 8 8 0) <br /> NOTE: A preliminary site inspection must be made and site appro I granted on all structures involving sanitary fa ilities 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 bee i 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 AP ROVED. <br />