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Burgett County Office of Zoning Administr for o <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 '� o o <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements o the ,8 L2 <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances.and the laws and 3 `a <br /> regulations of the State of Wisconsin. �i••t� <br /> ...... f:Y .1.!Bn......... .............:S.�.. ................................................................... ....... <br /> V .. ........ ........ <br /> OWNER (Pleax print) / CONTRACTOR or SURVEYOR or AGENT <br /> .U......... ..... .rG:.?........ 2............ ......................................................................... ....... d ;ern p <br /> ADDRESS ADDRESS I <br /> � 6.. .... .t.......... o.p..lpYKfj .................................................................................... . - i} <br /> ADDRESS SPntyo� N�^^T I` Lu/'SADDRESS °� Ev I S <br /> ....................................................................:,.�.7:VV.1....... i <br /> .................................................................................... ....... <br /> �� <br /> PHONE .� <br /> /^ PHONE -t :a.. <br /> . . . .......................................................... . . . ....... .. . . ............................................................... ....... . <br /> PLUER WELL DRILLER <br /> O <br /> ADDRESS ADDRESS m 0 <br /> O O <br /> PHONE PHONE Z ? r <br /> DESCRIPTION 4. SanitaryFacilities: P o ° �•(? <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details •• •• "•' , c <br /> New Building ....V Type of Construction: No. Bedrooms <br /> Addition ...,.,,,., r r,(„ ,r,,,,,•,••„•,,,,,,, Septic Tank Size Gals. <br /> Sanitary ..X.... Size ..../..(.... ft. x ....k ... ft. •• •fid <br /> RRiinpr Grading ...... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving ..... i r i <br /> .......... Area ........................................... Soil Type ..................... .. ....... <br /> Mobile Home Slope .................................. ....... n7 0 <br /> Privy .......... 3. Use (describe exactl , 1 -famil Perc. Rate ........................... ....... <br /> Well ......I... home,garage, motel, ) Dry Well .... M <br /> SubdivisionSeepage Trench ..... Z ' <br /> Camping Unit .......... Privy .. ....... .�> 1 i'� <br /> Seepage Bed <br /> — — — — — <br /> — -- ------------ ------------ ------------ — -- <br /> — — —. -- <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fi 1. A. c S <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is loco ed at ip• t( <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersec ion. ,t <— <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS.------------------------------------------------------------------- --- <br /> 0 <br /> 5. Lot$iize: Fig. A. 6. Location: 3” -.,,.i � <br /> ... .:. ....... ft. x .. .Cl. ft. — ........................ ...... sq.ft. ................... ....... ... .............................. ........ <br /> r <br /> D � �og TJX <br /> N a 0 <br /> O <br /> O = <br /> r <br /> v rt T <br /> Z <br /> o "o- < D _ 0 — — m <br /> T moo.�c — am asy <br /> O `< p <br /> 0 <D O <br /> O fn O •Z D <br /> o m <br /> = c <br /> ... . .. . ... .....:.................. . .............. .............. �.. :-. .... x o <br /> Signatureof Ow r or Agent Date o <br /> N <br /> Remarks . ::......��L.r....�...:................................................................................................................................... ..... r^ — <br /> m •• <br /> N <br /> ..............................................................................................?p,,,al <br /> r <br /> ................................. ..... <br /> //JJ � 4��g� go $ m <br /> Inspection Date ...:l.............. -� . ..... ...Aoni <br /> ...... ........................................ . q m <br /> Administrator ryo 0 o Vl <br /> NOTE: A preliminary site inspection must be made and sinted on all structures involving sanitary fa ilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this app)cation 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 i issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or 5pecifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND AP ROVED. <br />