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Burnett County Office of Zoning Administrator W <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMITto 3 3 �J <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and q M iL <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the ,8 44 : '� <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws nd 3 3 O —LEI <br /> Burnett <br /> the State of W�-/i�sconsi n. — ,Q <br /> jjv F l n It U u 1i R-e C. Y' n <br /> ............................................... ........ ..................................................................................... ...... _ 3Q <br /> OW R (Pie rind J CONTRACTOR or SURVEYOR or, AGENT $ <br /> ADDRESS � ADDRESS � I <br /> . . . ................................................................................ .A...... ..RESS.. ......................................................................... ...... <br /> ADDRESS DD <br /> . . ........................................................................... ...... <br /> PHONE PHON.... ....E <br /> i <br /> PLUMBER WELL DRILLER el <br /> -yP <br /> . . . ................................................................................ ..................................................................................... ...... <br /> ADDRESS ADDRESS 'm 0 _ <br /> o <br /> ........................................................................................... <br /> . ........................................................................... ...... o E <br /> PHONE P..HONE....... Z „�� r :yam <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° •n <br /> 1. Work: 2. New Building Details No. Bathrooms .. e :A <br /> New Building +� Type of Construction: No. Bedrooms ... i\ <br /> Addition Septic Tank Size Gals. .......... <br /> Sanitary .. Size ....aL.u.. ft. x ..,.6.Q.... ft. �. ••V <br /> Filling/Grading .......... Height........... Stories ............... 4a. Absorption Field Site: i <br /> ........ i ' <br /> Moving .......... Area ........................................... Soil Type ............................ .,� <br /> Mobrlle Home Slope .................................. ....... v ro <br /> .......... <br /> Prier .......... 3. Use (describe exactl '1 -family Perc. Rate ........................... ....... <br /> Well home,garage,motel, etc. Dry Well .... <br /> Subdivielon ,,,•,•,,,, Seepage Trench .. ....... o ?� '� ' <br /> Camping Unit .......... .................................................... Privy <br /> ......rA y &) i <br /> . ...... .......................... Seepage Bed / e-� <br /> ----------------------------------------------------------------------- <br /> Location of proposed structures and existing structures well sewage systems, roads, etc., should be sketched in Fi . A. E <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is local d at ,,� g <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersect on. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. _ :r o <br /> ------------------------ — — -- — — — <br /> -- — — ---- — ---------- ------ — <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq.ft. ....................................................................... ....... <br /> A <br /> J <br /> U1 <br /> 4 + : <br /> :1 0 <br /> 7 <br /> o <br /> p <br /> d <br /> J <br /> m <br /> 5�y V1. <br /> 4 y C M .N V U) r > C3 <br /> H Q < > > n = E. m <br /> m No.•< — am nn A <br /> � o< dCyJJ ; <br /> O (R O D —1 <br /> o 2 n 9 <br /> o c0 m <br /> n : m <br /> A <br /> O: m <br /> A ' <br /> Signatur of Owner or Agent Date 8 : , <br /> Remarks ... .�J..� k.,. .�........................ ....................... ......................................... <br /> .................. .......� '^� KLt(.f�G.' .....`.� �... . . .. . . . .. .......................................... . o o <br /> H 8 : 8 <br /> .................... ......./../............................................................................ ... ................. ........................................ .... <br /> Inspection Date . . ...-�r.... m <br /> .............. ... .. .............. .. .....9.......... ................................ vt . �noo �nm <br /> Zonin Ad nistrator 8 898 8 8 (A <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary fa ilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this application before a permit will <br /> be issued. Do not purchase or install a septic tank, do any plumbing or start any building until a permit has beer issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or pecifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND AP ROVED. <br />