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�7f <br /> Burnett County Office of Zoning Administrator 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < m :k <br /> _ <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use -o j3 <br /> ;3 <br /> Ordinance, <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. <br /> ...Cl..... ... h H <br /> H <br /> f' .................................... .. C . . o <br /> OWNER (Please rind/ Wr . . ...................................... _ <br /> P CO RACTOR or SURVEYOR or AGENT m .\\ <br /> ............................................................. <br /> ADDRESS - ADDRESS 0 <br /> m ipKp — <br /> ........................................................................................... ... ...... . ............................................................................... ;cs <br /> ADDRESS ADDRESS <br /> PHONE � .................................. <br /> PHONE <br /> ...................................................................................... .... ............................................................................................ ' <br /> PLUMBER WELL DRILLER D <br /> i 1 ' <br /> ........................................................................................... . ...... ... .......................................................................I....... O <br /> ADDRESS ADDRESS <br /> o <br /> PHONEPI I ......................................... ....................................... � ? .. <br /> DESCRIPTION 4. SanitaryFacilities: ° o 0 <br /> 1. Work: 2. New Building Details No. Bathrooms .......... o <br /> New Building .......... Type of Construction: No. Bedrooms .......... 0 <br /> Addition .......... .................................................... Septic Tank Size Gals. .......... <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... i <br /> FillingiGradingHeight............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... Soil Type .................................... i r <br /> Mobile Home Slope O <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... i <br /> Well home,garage, motel, etc.) Dry Well ,......... <br /> Subdivision .................................................... Seepage Trench .......... <br /> Camping Unit Privy .......... <br /> ...............................6.................... <br /> -------------------- Seepage Bed <br /> ------ — --------- i\ <br /> Location of proposed structures and existing structures,well, sewage systems, roads, etc., should be sketched in Fig. A. Include road � <br /> 0 <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- _0- <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. <br /> ________________________________________ C <br /> ______________________________ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... <br /> IN 0 <br /> L n <br /> t I �• o <br /> _ t s <br /> I <br /> l 1.yII m .a <br /> 0 <br /> O <br /> r L m to Z <br /> F <br /> M. <br /> <"H <br /> Z <br /> m <br /> o a , � <br /> o <br /> m <br /> ........................................................................... ...................................... C <br /> Signature of Owner or Agent o <br /> Date <br /> X 77 <br /> Remarks ......................................................................................................................................................................... m : m <br /> o A3 O <br /> .............................................................................................................................................................................I.......... <br /> II <br /> ........................................................................................................../77..11..".�..........,.......... i/ . <br /> ..... <br /> Inspection Date .... ............................ <br /> U <br /> GU o o N m <br /> .......:........ ................. <br /> mini�rator.....Z.o. n..n.g. <br /> 8 $ $ $ $ $ fm/7 <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 conveyedhere <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. <br />