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Burnett County Office of Zoning Administrator v CD o 0 <br />APPLICATION FOR 1,t�ARti-,ARY — LAND USE — BUILDING PERMIT <br />o <br />TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as <H -h <br />shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use - <br />Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3n <br />.... ....................... C: !Y <br />O NER (please print) CONTRACTOR or SURVEYOR or AGENT a <br />M <br />.:...?.....Q.v..c�.......................................................................................................................................... <br />A RESS ADDRESS 3 <br />e. -.,.... ....... ............. <br />ADDRESS ADDRESS <br />........................................................................................................................................... :s <br />PHONE PHONE :\ <br />.......... <br />PLUMBER WELL DRILLER <br />ADDRESS ADDRESS n 0 <br />o <br />........... o' <br />PHONE PHONE <br />z <br />DESCRIPTION 4. Sanitary Facilities: ° 0 ° <br />1. Work: No. Bathrooms <br />2. New Building Details •••••••••• ^ : o ; <br />New Building Type of Construction: No. Bedrooms .......... L <br />Addition Septic Tank Size Gals. .......... <br />................ ................. <br />Sanitary .......... Size ...r ...... ft. x ..'R....... ft. ......... <br />Filling/Grading .......... Height Stories 4a. Absorption Field Site: <br />Moving .......... Area Soil Type .................................... <br />Mobile Home Slope .......................................... vu <br />Privy .......... 3. Use (describe exactly, 1 - family Perc. Rate ................................... <br />Well ., ho e, garage, motel, etc.) Dry Well .......... ........ <br />Subdivision .......... UiY Seepage Trench .......... <br />i, ..........�. <br />Camping Unith. Privy <br />..................... .... <br />Seepage Bed ........ i <br />--------------------------- -------------------------------------------�:, <br />Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road �j , <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 -I <br />STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br />-------------------------------------------------------- — i <br />5. Lot Size:(� ���• Fi9• A. 6. Location: <br />................ ft. ........ ft. —....................,.''....^........ sq. ft................................................................................ <br />{ <br />co z <br />r o <br />3 a <br />3 <br />Q <br />Q4r <br />Q, L................... ..... :�Y�........ <br />RI <br />ature of Owner Agent Date <br />Remarks......................................................................................................................................................................... <br />........................................................................................................................................................................................ <br />........................................................................................................ . <br />Inspection Date..�.'�!?•�:�...... ........:........-... ....?'.�................... <br />....................................... <br />Zoning Admi strator '1 <br />.C• <br />fNr v w <br />Z <br />C <br />m <br />�aa��'aiN <br />N <br />At <br />M <br />'0' Ln <, w <br />y' mM <br />,� c <br />a <br />Z O 0.: . <br />. . ' a <br />vc <br />.... <br />G(D ..... <br />p <br />X <br />70 <br />-n <br />m <br />CID <br />Co E <br />p <br />n; ds <br />O ch 0 LrI CO 0 (NT m <br />go0 0 0 0 Cn <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 must 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 />ng until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br />✓vith 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 />