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<br /> Burnett County Office of Zoning Administrator l� o 0
<br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3
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<br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as <
<br /> ._.
<br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m e
<br /> Ordinance, Sanitation Code, and with all other applicable County Ordina es and the laws and regulations of the State of Wisconsin. a.
<br /> � iJ. .....l�i..� r.: :................................ ...... �.P..l..l.��....f A. PK!�.........................................
<br /> CONTRACTOR o � � m
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<br /> OWNER (please print) I t r URVEOR or AGENT m
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<br /> ADYRESS �...... .AD R SS ..... ...... .... .. .... ...... .... . . ...... ..... ... a
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<br /> X47 .. 1at�. : � , ..� .... .. . ...... '. . ....� :.... ....................
<br /> ADDIRESSI ADDRESS
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<br /> PHONE . .......................................................................................... V
<br /> PHONE
<br /> PLUMBER .WE....LL.. .. .... ................................................................... '
<br /> ...D..RI..LLER....
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<br /> ADDRESS ADDRESS
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<br /> . . .................................................................... .P.HON.......E................................
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<br /> PHONE Z o
<br /> DESCRIPTION 4. Sanitary Facilities: ° o
<br /> 1. Work: 2. New Building Details No. Bathrooms .......... o
<br /> New Building ,,,,,,,,,, Type of Construction: No. Bedrooms .......... ^: ': T
<br /> Addition ... ...... .................................................... Septic Tank Size Gals. ..........
<br /> Sanitary Size ft. x ft.
<br /> Filling/Grading ,,,,,,,,,, Height............. Stories ............... 4a. Absorption Field Site:
<br /> Moving .......... Area ........................................... Soil Type .................................... r o
<br /> Mobile Home .......... Slope .......................................... _ .+
<br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ...................................7p
<br /> Well ,,,,,,, „ home, garage, motel, etc.) Dry Well ..........
<br /> Subdivision Seepage Trench .......... d
<br /> ....................................................
<br /> Camping Unit .......... Privy . ........
<br /> .................................................... Seepage Bed
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<br /> Location
<br /> -------------- ----- -----------Location of proposed structures and existing structures, well, sewage systems,.roads, etc_, should he sketched in Fig. A. Include road e
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<br /> setback, side and back Yard dimension and location and setback from all bodies of water_ If property is located at a highway inter aa -
<br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING L'Cn r
<br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. i o
<br /> --_--____----__---___.-------------- ___ J
<br /> 5. Lot Size: Fig, A. 6. Location:
<br /> ................ ft. x .............. ft. — ............................... sq. ft. ............................................................'.............^ t i
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<br /> Signature of Owner or Agent Date
<br /> X 37
<br /> Remarks ......................................................................................................................................................................... T m
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<br /> Inspection Date ....................................... .....'.....J.`VL. .. �I ..�._..^....... ;�T m to o rn o u,
<br /> Zoning Administra S- 1 0 0 0 0 0 0
<br /> NOTE: A preliminary site inspection must be made and ite 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, (10 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 conveyed here-
<br /> with is found to exist. Changes in plans or specifications shall not be made without approval of the Zoning Adm inistratol .
<br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED.
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