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Burnett County Office of Zoning Administrator d a;- o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> o 5 <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as � 7 � r.5j <br /> h <br /> shown herein. The undersigned agrees that all work shall become in accordance with the requirements of the Burnett County Land Use <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a gJ <br /> n <br /> . Y <br /> OWNER (please print) / CONTRACTOR or SURVEYOR or AGENT o. <br /> 7. �� � . <br /> ADDRESS . .......................................................................................... � �O <br /> ADDRESS .. <br /> ........................................................................................... .A......... .......... <br /> ........... <br /> ........ <br /> ...... <br /> ........ <br /> ....... <br /> ....... <br /> ................ <br /> ..... <br /> ADDRESS DDRES....S <br /> PHONE . .......................................................................................... � <br /> PHONE ,4 <br /> ........................................................................................... <br /> PLUMBER . .......................................................................................... <br /> WELL DRILLER <br /> ........................................................................................... ............................................................................................ <br /> ADDRESS ADDRESS <br /> m G1 <br /> O O <br /> ct <br /> PHONE................................................................................ . .......................................................................................... �Z j <br /> PHONE <br /> DESCRIPTIONr <br /> 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms ' <br /> 2. New Building Details <br /> New Building .,u.... TypeConstruction: No. Bedrooms .......... z <br /> Addition .c inF Septic Tank Size Gals. .......... L <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... <br /> Filling .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Soil Type ..................... <br /> .......... ........................................... ................. <br /> Grading Slope ............................... ..... tl ' u <br /> Perc. Rate ................................... , <br /> Mobile Home ....... 3. Use (describe exactly, 1 -family 1 <br /> Privy .......... hom garage, motel, etc.) Dry Well .......... <br /> Well /4Y'a 2� Seepage Trench 1.............................. <br /> Subdivision .......... Privy <br /> ........_ �- i <br /> .................................................... <br /> Seepage Bed .......... <br /> ---------------- ------ -------- -------- , v1 <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road i [ 6 (y <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- O. <br /> section, show the intersecting highways and the setbacks required along them and at the Intersection. CLEARLY LABEL EXISTING < <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. �i`. o <br /> ------------------------------------------------------------------ --- <br /> 5. Lot Size: Fig. A. 6. Location: 1`� '� <br /> ................ ft. x .............. ft. — ............................... sq. ft. ............................................................................... :� <br /> m <br /> 0 r 0. <br /> O <br /> s <br /> T <br /> d <br /> m <br /> 1 <br /> 3 N r N W Z <br /> < <br /> Oo U1 C <br /> Z <br /> ge <br /> pri <br /> cp <br /> 0 37 <br /> ^ m <br /> u..:.../ ...........�? ?2nd ....71.-..3..�...... N�l\� p <br /> o [ c <br /> Signature of Owner or Agent Date X i <br /> „ M <br /> Remarks ......................................................................................................................................................................... ro p <br /> ........................................................................................................................................................................................ <br /> InspectionDate ....................................... ...//Jy .............................. ......_..-..�.....I'y�......................... c. 0 0 0 0' o <br /> ZoningAdmir ator TJ o 0 0 0 0 <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 lie ettacherl 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 he made without approval of the Zoning Adm inistratui. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />