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Burnett County Office of Zoning Administratord 0 0 <br />APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT �. <br />TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < N :(j- <br />shown <br />Ushown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m c <br />Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br />Q O <br />c�?L, --- .... ..... ... .. ............. � .:..... - ...,-.................... , <br />OWNER (please print CONTRACTO or SURVEYOR or AGENT m <br />`.... G .............................. CL <br />ADDRESS ADDRESSCD <br />rt 3. <br />ADDRESS ADDRESS <br />............ i <br />PHONE PHONE :�- <br />:.A <br />...................................................................................................L ....D.RI..........LLER..................................................................... : e� <br />PLUMBER WEL <br />.....E—S"S............................................................................. <br />ADDRESS ADDR.ES <br />00 <br />........................................................................................................................................................................... z ' <br />PHONE PHONE <br />DESCRIPTION 4. Sanitary Facilities: °0 ° <br />1. Work:No. Bathrooms 7 <br />2. New Building Details <br />New Building .......... Type of Construction: No. Bedrooms °o <br />AdditionSeptic Tank Size Gals. .......... <br />Sanitary.......... Size .............. ft. x .............. ft. <br />Filling/GradingHeight ............. Stories ............... 4a. Absorption Field Site: <br />Moving Soil Type .................................... <br />.......................................... r <br />° <br />Mobile Home Slope .......................................... + <br />Privy ...,,..... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br />Well home, garage, motel, etc.) Dry Well .......... <br />Subdivision........Seepage Trench .......... <br />Camping UnitPrivy <br />................................................... Seepage Bed <br />Cn <br />Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road C: <br />setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- ° <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. y <br />o' <br />---------- ----------------------------------------- _ <br />5. Lot Size: Fig. A. 6. Location: <br />................ ft. x .............. ft. — ............................... sq. ft................................................................................ <br />ems- c� C: S hL L C_ cn <br />n <br />jj <br />T r 0 Q. <br />3 <br />j <br />OZ •� <br />d <br />3 <br />t9 <br />N. <br />�w�2)WCD <br />A �_<�-f <br />co Efl n °• •c — -' n <br />NCL <br />Nco <br />yCD D m <br />0 00 a <br />cn <br />0 <br />....... ........ ....... C <br />Signature of Owner or Agentate ° <br />X <br />- <br />Remarks ......................................................................................................................................................................... -nmCD :� O <br />CD <br />u <br />..................................................................................................................................................................................... <br />Inspection Date ....................................... U .....2a...... <br />.. V w ro <br />UUT1 <br />Zoning Admin�sia,�C0000000 <br />N <br />JOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br />lefore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br />his application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build - <br />,)g until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br />✓ith is found to exist. Changes in plans or specifications shall not he made without approval of the Zoning Administrator. <br />SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />