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Burnett County • Office of Zoning Administrator W CD 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT . <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as H <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use c <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> ,p �lL1r n C Q <br /> :....... .. . I i � I{(��/ T r " r O 1. . .................................................. ............................. <br /> P CONTRACTOR or SURVEYOR or AGE4 a <br /> OWNER (please riot <br /> S'.j.. ..C..,,..........4: -?. .. ..4�...�............................ ............................................................................... C <br /> ADDRESS ADDRESS <br /> ......... .......... .......................... .................... .... ...........................................................................................).6 <br /> S <br /> ADDRESS ADDRESS <br /> d*e ..................................... ............................................................................................ <br /> HPE' � �� PHONE <br /> M. <br /> Gip th 3 <br /> ............... <br /> ............................................ .W........ D .............................................................. <br /> PLUMBER ELL RI.. LLER \ �n1 <br /> ....................................................... <br /> ADDRESS ADDRESS <br /> ( - o <br /> ............ W o <br /> PHONE PHONE Z H <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details o <br /> New Building Type of Construction: No. Bedrooms ...e� .. 1-1:U, Z <br /> Addition [�.' .rt'............. Septic Tank Size Gals. .......... <br /> v .. a.y..... .. .,r. :W <br /> Sanitary Size ..a... ..... ft. x �........ ft. <br /> Filling .......... Height............. Stories ............... 4a. Absorption Field Site: b_ <br /> SoilT e ...................... .. .......... T� <br /> Moving .......... Area ................................... Type 0 <br /> Grading Slope .......................................... r , <br /> Mobile Home .......... 3. Use (describe exactly -famil Perc. Rate ................................... <br /> Privy •....•..., home,garage, motel, etc.) Dry Well rb :� <br /> Well Seepage Trench .......... �► <br /> Subdivision Privy <br /> .......... <br /> Seepage Bed /IX.� `c <br /> — ------------------------------------------------------------ <br /> Location of proposed structures and existing structures,well, sewage systems, roads, etc., should be sketched in Fig. A. Include road :> <br /> setback, side and back s <br /> yard dimension and location and setback from all bodies of water. If property is located at a highway inter- � � fl- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING :T <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. y <br /> O. <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: �: F <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... t., <br /> :> Cn <br /> CD <br /> r+ <br /> 0 :� <br /> Lo <br /> o <br /> `s <br /> —n <br /> C, <br /> :L o <br /> � m <br /> co <br /> CD <br /> CD cn r— cn W <br /> cD N Q 0- <br /> -0 <br /> cn <. C : <br /> 0 T H C <br /> Z O 0. `D `CD <br /> o . <br /> o <br /> O <br /> U m <br /> ..... .. ....... .... ........... ..................................... [...o.�..�.......... <br /> .. ..3 0 p <br /> Signature of O er gr A ent Date ; X <br /> 'y <br /> Gsn�X L iz { 7 „ : M <br /> Remarks ......... ................. ... ?�r ...................................................................................................................... CID <br /> m <br /> t» <br /> Inspection Date ....................................... y\' 0 0 o O o cn 'm <br /> ZoningAdmi�or .. .. OOOC)0CCn <br /> DOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> iefore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> his application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> ng until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> vith 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 />