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__- /'-�.• .ter-, <br /> Burgett CoUnty Office of Zoning Administrator a) CD o 0 <br /> '-APPLICATION FOR'SANITARY — 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 ; :,• <br /> shown 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 o the State of Wisconsin. 3 Q <br /> _ a 3Z N h <br /> '. '..Y ........O.`. .. �.�i. ........................................ ........ .......� ....... ................................ O <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGE T a V <br /> ?..' .. . lr`......t�v�...s.�- .:....................... ............................................................................................ <br /> ADDRESS ADDRESS <br /> Co <br /> ....................................................................... ............................................................................................ <br /> ADDRESS ADDRESS <br /> ........................................................................................... ............................................................................................ <br /> PHO PHONE <br /> n...C......................................... ............................................................................................ � <br /> PLUMBER � WELL DRILLER <br /> ADDRESS ADDRESS G) <br /> ............................................ P...H..ONE.. .... .. .............................................................................. o' <br /> PHONE z y r �c <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms <br /> New Building Type of Constr ction: No. Bedrooms i*' L.... <br /> CD <br /> Addition Q+ �P Y Septic Tank Size Gals. .... ..... <br /> .... ................ ..Sanitary t p y qC.., Size J.(c....... ft. x ..7 .... ft. Cf} <br /> Filling .......... Height............. Stories ............... 4a. Absorption Field Site: its, <br /> Moving Area ........................................... Soil Type ..........5`ti't4....s........ m <br /> :tb o <br /> Grading Slope .......................................... <br /> y <br /> Mobile Home ...X.. 3. Use (describe exact) 1 -famil Perc. Rate ................................... i- r <br /> Privy .......... home,garage,motel,etc.) Dry Well <br /> Well (;•• Seepage Trench .......... <br /> .................................. -� <br /> Subdivision Privy <br /> .......... .................................................... . <br /> Seepage Bed \�� <br /> —————————————————————————————————————————————————————————————————————— C/) \ <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road � � a <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 p� <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> --------------`------------ ,l �e <br /> 5. Lot Si e- Fig. A. 6. Location: <br /> Ai?.:`►.... ft. x �_.. ... ft. — ....I. ......`............. sq.ft. ............................................................................... � <br /> v <br /> N � 'o. <br /> 0 <br /> 5' <br /> �J <br /> CD C <br /> Cr <br /> lT <br /> . V1•(A : d <br /> b * m <br /> Z o o fD CD <br /> o 3 �. <br /> rn <br /> CD <br /> �. ....... `............................... ......' . ......... ..v.:..� € s c <br /> .... <br /> Signature of O er or Agent Date �* — <br /> X <br /> Remarks -n ' M <br /> m <br /> Cl) <br /> 6 <br /> ........................................................................................................................................................................................ .� u <br /> .................................................................................... ...... ................................. .............. <br /> .................... ........ <br /> ,(� y�,�-�J ~` — o � cNnm <br /> Inspection Date ....................................... ram......... ..... ... . o 0 0 0 0 0 <br /> Zoning Administrator o 0 0 0 0 o 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 /> ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed 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 />