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Burnett County Office of Zoning Administrator Ln - '0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3. \ <br /> 0 <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 Land Use n C <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the Stat <br /> r.. of Wisconsin. <br /> .....m .N �oNA............ .t5.....� ...�........ .. ................ ...S... . ? <br /> 3» <br /> OWNER (please print) CONTRACTOR or SURVEYORtr AGENTKt o. <br /> `�..�b..... `ia..ae ..S�..a!1 ..S.a .....V��aC ......: �5 ...................................... <br /> ADDRESS : ADDRESS <br /> .... ............................................................................................ a <br /> ADDRESS ADDRESS <br /> q .4....... ..`�` 4.................................. ............................................................................................ s' <br /> PHONE................................................................................ PHONE <br /> PLUMBER WELL DRILLER y <br /> ........................................................................................... .A............................... <br /> ................... <br /> ....... <br /> ................... <br /> ............... O <br /> ADDRESS DDRESS 0 o <br /> ................................................... ....................................... o' v\ <br /> PHONE PHONE Z r <br /> DESCRIPTION 4. Sanitary <br /> Facilities: ° o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details """"" E o <br /> Type of Construction: No. Bedrooms .......... <br /> Addition ry Y� Septic Tank Size Gals. .......... <br /> Sanitary .......... Size ...{ .... ft. x ft. """"" <br /> w 1 4a. Absorption Field Site: 4f . <br /> FluinglGrading .......... Height.....A Stories .....l......... <br /> Moving .......... Area 5 1`r . Soil Type .................................... o f <br /> Mobile HomeSlope .................................I........ » <br /> .......... <br /> PrivyPerc. Rate ................................... <br /> ,,........ 3. Use (describe exactly, 1 -family t <br /> Well ,,,.,,,,., home,garage, motel,etc.) Dry Well .......... <br /> .......... y •�`` <br /> Subdivision Seepage Trench 1 � E <br /> ...............��'.4r�Qi........................ Privy <br /> Camping Unit .......... """"" J <br /> .................................................... Seepage Bed .......... I <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 yard dimension and location and setback from all bodies of water. If property is located at a highway inter- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> `- <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o---------------------------------------------------------------------- <br /> - <br /> o - p <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq.ft. ..................................................................... ........ <br /> N O <br /> o <br /> o <br /> u <br /> Y : m :` <br /> 0 <br /> � �1 ��Z <br /> etoeo��� z 64CAV _ <br /> �e <br /> ?Z g <br /> M Nr 9 � m m 2 <br /> C m m c m <br /> m Wn m•< m �_ nE <br /> 01_. d D <br /> 9Z o 0' <br /> � ' 3 <br /> Signature of Owner o g t Date <br /> X � <br /> Remarks ................................................................................................................................................... ..................... „ rn <br /> M <br /> v <br /> .................... .. . :V T <br /> ° � Nm <br /> Inspection Date ....................................... .Q!n!-l!�..:..�..:/.... ........ .......................... <br /> 1�7Zoning Adminis �J 8 8 8 8 8 8 to <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 conveyed here <br /> with is found to exist. Changes in plans or specifications shall not tie made without approval of the Zoning Aclm inistrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />