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=�17TI ilk ) }p <br /> i - <br /> Burnett County Office of Zoning Administrator o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT a <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and � <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the yJ <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws nd 3 KD <br /> regulations of the State of Wisconsin. '; • <br /> L ;n m <br /> ...�(ER (pie �. ....�....!4iz......................................... CTOR.............................................................. ...... <br /> OWNER (pleasLeprint) CONTRACTOR or SURVEYOR or AGENT $ <br /> ... q�.. a :/ :1 <br /> .......................................... ............... .......................... ...... i, R <br /> ADDRESS r ADDRESS <br /> l <br /> FQ E p E..2...4.Ct....f.w.!.....r..�5.... . 3..7....... <br /> ......... ....... ; <br /> ADDRESS ADDRESS <br /> ..�.7. ..d'..."� <br /> - ............................................................... ..................................................................................... ...... <br /> PHONEPHONE <br /> ............................................................................... <br /> PLUMBER WELL DRILLER <br /> . . . ................................................................................ ..................................................................................... ...... O <br /> ADDRESS ADDRESS G <br /> _. <br /> c <br /> ........................................................................................... <br /> ........ ........................................................................... ...... O ,+ <br /> PHONE PHONE.. ZN r <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details ••• c <br /> New Building No. Bedrooms <br /> •• ..... <br /> .......... Type of Construction: <br /> Addition ,•••„•„. Septic Tank Size Gals. .... <br /> Sanitary .......... Size .....7. . ft. x ...<C..l...... ft. .......... . <br /> Filling/Gradingy t 4a. Absorption Field Site: <br /> Filling/Grading <br /> .......... Height.............. Stories ............... <br /> Moving .......... Area Soil Type ............................ ....... <br /> ......................................... o <br /> Mobile Home ... . Slope .................................. ....... ” <br /> Privy 3. Use (describe exactly, 1 -family Perc. Rate ........................... ....... <br /> - <br /> Well .......... home,garage,motel, etc.) Dry Well ... <br /> Subdivision Seepage Trench .. ....... ..... o <br /> Camping Unit .......... V y .. ....... --1 <br /> ( Priv <br /> ......... .................. ....................... <br /> ------ Seepage Bed <br /> --------. ....... <br /> Location of proposed structures and existing structures well sewage systems, roads, etc., should be sketched in Fit . A. - ��' <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is local d at I' i <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. ii. <br /> _----____ -------------------------------------- -- <br /> 5. Lot Size: Fig. A. 6. Location: 61� <br /> ................ ft. x .............. ft. . ............................... sq.ft. ....................................................................... ....... <br /> I jI/ .N o <br /> o J <br /> f <br /> I` <br /> v <br /> J � <br /> O <br /> A <br /> d <br /> J <br /> b <br /> N <br /> N N N n c c <br /> ' nm an9 <br /> v C y J J 3 <br /> Z 8 N ; m m <br /> O N m ;!N y 1 d <br /> y <br /> e c m <br /> 0 : O <br /> ........... ......... A <br /> Signature of Owner or Agent Date 8 <br /> Remarks m y <br /> ........................................................................................................ ....... ........ ............. .. ....... . . ........... ........ .... <br /> m <br /> Inspection Date ....................................... .. l.[(.1. <br /> ZoningAdministrat 8 8 8 8 8 8 rA <br /> NOTE: A preliminary site inspection must be made and site appr? v granted on all structures involving sanitary facilities before onstruction <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 APPROVED. <br />