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Burnett County Office of Zoning Administrator d / o
<br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT
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<br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located os N •* ay
<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 T..+
<br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 i9M
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<br /> OWNER (please runt) CONTRACTOR or SURVEYOR or AGENT a
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<br /> Dp�$S t/ �A(� 3 ADDRESS
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<br /> ADDRESS ��11 . .. .. . ...... .
<br /> ADDRESS
<br /> PHONE PHONE
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<br /> PLUMBER WELL DRILLER \
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<br /> ADDRESS AD.. ..DRESS m dt
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<br /> PHONE
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<br /> DESCRIPTION 4. Sanitary Facilities: ° o ° rl
<br /> 1. Work: No. Bathrooms ..........
<br /> �J 2. New Building Details � o '
<br /> New Building X.... Type o structio I /' / r No. Bedrooms .......... 0
<br /> Addition ,,,,.,,,,, ,,,,,,, „ , ,�, ], ,�„a7 �6 Septic Tank Size Gals. .......... 0 Z
<br /> Sanitary .......... Site ..?���... ft. x ... ft. 14
<br /> .......... V�
<br /> '. 4a. Absorption Field Site: ? m,•
<br /> Filling/Grading ,,,,,,,,,, HelgWt �....... torte .....�..... .
<br /> Moving .......... Area `........... Soil Type ................ .. .. �
<br /> Slope .......................I..................
<br /> (� : ��
<br /> Mobile Home .......... P
<br /> Privy .......... 3. Use (describe exactly, 1 -family Fare. Rate ................................... �,
<br /> Well Dry Well .......... 7 6
<br /> .......... horr gar,6(motel, etc.)
<br /> CC�7�/ ..........
<br /> Subdivision .......... O�ex<'f Seepage Trench
<br /> Camping Unit ........ CY y
<br /> Seepage Bed ..........
<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 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. -L v,
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<br /> 5. Lot Siz //leaf, Fig. A. 6. Locatiop;r/, ,
<br /> ':. .. ft. x ..�r..�'.. ft. — _l..J. ...... sq.ft. ..........l��l: ��:���...Y% .`... ...............................` o
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<br /> Si ture of Owner or Agent Date ° p
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<br /> emarks .................................... ......................................................... . .......................................................................
<br /> ............. ... .......U. ......�/�r,uiti f. .�G ..t..................................... .... ................ .
<br /> Inspection Date ....................................... f..:J..._'tili.�...... .l` .. �j u ren o' 0 0 0
<br /> � Zonin dministrator :-" 8 8 8 0 8 0
<br /> NOTE: A preliminary site inspection must be made t d 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 lie 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 ITe made without approval of the Zoning Administrator.
<br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED.
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