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Burnett County Office of Zoning Administrator �' c <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT W <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 'r7- <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements ol the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3iol ,JJ <br /> regulations of the Stat%Wisc nsin. --,L <br /> 4f�� <br /> ............................................................ . .................................................................. ...... <br /> ...... <br /> ... .. <br /> ............ . . <br /> OWNER 1 ase print) CONTRACTOR or SURVEYOR or AGENT <br /> .a.... ..al..6...... ...-5.�.......:........................................... .................................................................................... ....... <br /> ADDRESS ADDRESSPIrl, <br /> / I I `ygy� <br /> ADDRESS ADDRESS <br /> ........................................................................................... .P....HO...NE............................................................................ ....... :W <br /> PHONE <br /> ........ .................................................................................. .................................................................................... ....... <br /> PLUMBER WELL DRILLER iq <br /> ........................................................................................... .A..DD.....R..ES'E'S"S..................................................................... ....... <br /> p ? <br /> ADDRESS N G <br /> < : ( <br /> . . . ................................................................................... . .......................................... ............................... ....... <br /> PHONE P..HON......E Z <br /> DESCRIPTION 4. SanitaryFacilities: ° o ° " <br /> 1. Work: 2. New Building Details No. Bathrooms .. ....... o <br /> New Building ••••••.... Type of Construction: No. Bedrooms .. ....... R <br /> Addition .................................................... Septic Tank Size Gals. .. ....... <br /> Sanitary .......... Size .............. ft. x .............. ft. .. ....... <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... Soil Type ............................ ....... r <br /> Slope .................................. ....... <br /> Mobile Home ••••••.... .. <br /> Privy �.... 3. Use (describe exactly,'1 -family Perc. Rate .......................... ....... <br /> Well .......... home,garage, motel, etc.) Dry Well . ........ m 1t i i i <br /> Subdivision Seepage Trench . ........ o k, <br /> .......... .......... .. .. .......................... <br /> Camping Unit IV Privy . ........ <br /> .......... ......................... .................... <br /> ' Seepage Bed <br /> ------------------------------------------------------------------- — S 3� <br /> — y <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fi 3. A. : �Jj c �R <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is loca ed at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersec ion. d <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. L <br /> _______________________________________________ <br /> RZ <br /> 5. Lot Size: Fig. A. 6. Location:f <br /> ................ ft. x .............. ft. — ................ sq.ft. ............ ....................... ........ U <br /> N O <br /> o <br /> V:n <br /> �0 <br /> (,Icd o <br /> 6J e( o <br /> d <br /> A <br /> ICI Vy <br /> 37 r DOo IA rn <br /> IT <br /> m NQ.< am nn � <br /> S S o o a C y n n 3 <br /> O(� G p n to <br /> Zo `2 D 1 <br /> V � �' tea . <br /> M <br /> 0 <br /> m <br /> S.ignat......u. ....re..of... .....wner...... ...A..gent..... ............................... ................D.. . <br /> a..te................. S v <br /> O ...or.. o <br /> Remarks a <br /> u <br /> $ : S <br /> Inspection Date ....................................... .... . .......... .. .... <br /> ....` Q.1(,�G.. .1.(�.......... ..... u, u, o o v, m <br /> Zoning Administr or !.>T, o S 8 S 8 U) <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary ft cilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this app ication 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 beE n issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE ANDA PROVED. <br />