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Burnett County Office of Zoning Administrator 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as C •� <br /> shown herein. The undersigned agrees that all work shall be done In accordance with the requirements of the Burnett County Land Use m .` ., <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a �+.1 <br /> L ........... ..............«J..................................... o .s .................................... N <br /> OW�'R (plea�rint/ln� ` VNRACTOR or SURVEYOR or AGENT o. <br /> (...�.. �.�..y...%...1.. ..J.(...�/!...................................... ............................................................................... a <br /> A<DQ�H ESS -77 ADDRESS * <br /> .1.i .. ... ..... ....��./. /./ .................................. . . . . . ................................................................................. <br /> ADDRESS J ADDRESS <br /> . . . . ................................................................................. <br /> . V <br /> PHONE PHONE <br /> .......... <br /> ........................................................................................... .................................................................................. <br /> PLUMBER WELL DRI LLER i <br /> 0 \ <br /> ADDRESS............................................................................ .ADDRESS............................................................................ <br /> ............ o <br /> ........................................................................................... ................................................................................ Z <br /> PHONE PHONE � <br /> r <br /> DESCRIPTION 4. Sanitary Facilities: R o ° <br /> No. Bathrooms :W <br /> 1. Work: 2. New Building Details •""""' o <br /> No. Bedrooms <br /> New Building ........., Type of Construction: ' i <br /> Addition .................................................... Septic Tank Size Gals. .......... i <br /> Sanitary .......... Size ft. x ft. """"" <br /> FillingiGrading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area Soil Type .................................... i r- <br /> 0 <br /> Mobile Home .......... Slope .......................................... H <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... i <br /> Well .......... home,garage, motel, etc.) Dry Well .......... <br /> Subdivision ,t/„ Seepage Trench .......... <br /> .................................................... <br /> Camping Unit Privy <br /> .......... .......... <br /> .............. <br /> Seepage Bed .......... <br /> N <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A- Include road Q <br /> setback, side and back yard dimension and location and setback from all bodies of water. I1 property Is located at a highway inter- e- <br /> section, show the Intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> 0 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> 5. Lot Size: Fig A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... <br /> O <br /> w <br /> 2/Wio <br /> o <br /> s <br /> Z <br /> 0 <br /> W <br /> 7a VIr v m m2 <br /> c w % c m <br /> m n < �. n E <br /> m — m <br /> T. <br /> off. yn <br /> m <br /> €S o <br /> � a � <br /> �, <br /> D Ing <br /> �lo........................................................................ ...................................... 0 <br /> Signature of Owner or Agent Date <br /> X <br /> T �Remarks ......................................................................................................................................................................... : m.� � � <br /> m : <br /> el <br /> O « T <br /> N W N m <br /> .. <br /> Inspection Date ....................................... f�..�.................. ................ to.. ............... U u, o N o g m <br /> ZoningAdmi nis rator its i I' 0 0 0 0 0 N <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 trust 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 conveyer) here- <br /> with is found to exist. Changes in plans or specifications shall not be made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />