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Burnett County Office of Zoning Administrator o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT3 <br /> d <br /> o ✓— <br /> TO THE ZONING ADMINISTRATOR The undersigned hereby makes application for a Permit for the work described and located as < N � <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Lard Use m C <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisdonsm. 3 M <br /> E . . se pri ..... .............................. ... N.. . C. . R. . .....V.......................T <br /> ............................. <br /> .. <br /> OWNER Iplease print) CONTRACTOR or SURVEYOR or AGENT <br /> Bcl7F, <br /> ......... .... ........................ <br /> .................................................. ......... <br /> ADDRESS ../...... ...../................................................ ADDRESS............... n <br /> ru rices <br /> ADDRESS ADD.... <br /> . .RESS <br /> c........................................................................................... ...PH..ONNE.. ........................................................................�L......., i <br /> PHONE <br /> ............................................................................ . . .............. .........................................._............... ......... i <br /> PLUMBER WELL DRILLER.. IN Z <br /> O <br /> ADDRESS ADDRESSo ' <br /> n <br /> ........................................................................................... ..................................................................................L........ o' <br /> PHONE PHONE Z H <br /> DESCRIPTION 4. Sanitary Facilities: O 8 0 <br /> v <br /> 1. Work: 2. New Building Details No. Bathrooms i......... o <br /> New BuildingT No. Bedrooms L........ ' a <br /> .......... Type of Construction: <br /> Septic Tank Size Gals. ......... <br /> SanitarySize .............. ft. x .............. ft. I......... <br /> .X.... l <br /> EillinglGrading ,.,,,,..,, Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area Soil Type .......................... ......... <br /> Mobile Home Slope ................................1......... 0 o <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ......................... ......... <br /> Well home,garage, motel, etc.) Dry Well <br /> SubdivisionSeepage Trench .... <br /> Camping Unit .......... .............................I...................... Privy . ....... YO <br /> .................................................. '1 <br /> ----- --------------------- --------- Seepage Bed— ——— -- �t} <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc.,should be sketched in Fig_ A. Inclu e road jj <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property Is located at a highwa inter <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXI TING 1 < <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. f ^ o <br /> _________________________—__-----_—___—____--_--- ------_.___.___—___ " L <br /> ESQ <br /> N. <br /> 5. Lot Size: Fig. A. 6. Location: 35...73.......' / `✓ �1 <br /> ................ ft. x .............. ft. — ............................... sq.ft. <br /> 5.... <br /> ... _ I . <br /> n � i <br /> w <br /> o w <br /> [� 4 s <br /> �o <br /> II <br /> 3 <br /> o � d <br /> :E <br /> T. so a = d n <br /> O m y n m <br /> Z O O <br /> O > an o 77 <br /> e <br /> A <br /> a <br /> � .. <br /> , o <br /> Signatur of6z Owner or Agent Date <br /> X 37 <br /> Remarks ............................................................................................................................................................... .... m <br /> ............................................................................................................. <br /> ............................................................................................................ .................. ...i............................................... : <br /> r M T <br /> Inspection Date ....................................... . .4�1.�i�..f....f.. (7U" ..y i .d:!Y -:.L..... E n E U o m <br /> Zoning Admih'istrator <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 percolating test must be attached to <br /> this application before a permit will be issued. Do not purchase or install a septic tank, do any plttmbing 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 tote Zoning Administratot. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE .AND APPROVED. <br />