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Burgett County• J ��� /ham Office of Zoning Administrator d CD 0 0 <br />1�4 <br />APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 � <br />TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as H :Q <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 of the State of Wisconsin.CL <br />Q V N + <br />Q..F. F ..... ���......'.1.......:e..?............s &6.�... ............................................................................................ <br />OWNER <br />(please print) CONTRACTOR or SURVEYOR or AGENT Q �� <br />,S7pY /1'TL 13c)C `�/y 3 voN.t v co a ;'\CD <br />ADDRESS ADDRESS R <br />.............................................. <br />ADDRESS <br />PH/O�NE <br />....................... <br />PLUMBER <br />S.�.3..... <br />� <br />ADDRESS <br />.......................................................................... <br />ADDRESS <br />........................................................... <br />PHONE <br />y c. j / �). <br />............................ t ......... .... ........................ <br />WELL DRILLER <br />L'. -7 '.'T . <br />..................................... ....................... <br />ADDRESS <br />............................................. <br />PHONE <br />1� <br />.......... W <br />.................................................. <br />I h o <br />........................................................................................................................... <br />PHONE <br />DESCRIPTION 4. Sanitary Facilities: ° o <br />J <br />1. Work:' 2. New Building Details No. Bathrooms ..... o <br />New Building No. Bedrooms .......... :� -a <br />.......... Type of Construction: ;� Co ; <br />AdditionSeptic Tank Size Gals. J..®P..a <br />.................................................. <br />Sanitary ...`.'�. Size .............. ft. x .............. ft. :� <br />Filling .......... Height ............. Stories ............... 4a. Absorption Field Site: <br />Moving .......... Area ............. Soil Type ...................... ` r <br />............. <br />Grading Slope .......... ...1-4)....�...�'..�.4, o <br />Mobile Home .......... 3. Use (describe exactly, 1 - family \ <br />Perc. Rate .........-... 3 .................. <br />Privy.......... home, garage, motel, etc.) Dry Well <br />Well / Seepage Trench ......... W <br />....... ........... 7 ............. <br />Subdivision... Privy i <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 �, C7 Cn <br />setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- °- m <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. a o <br />--------- -------------------------------------------------------- <br />5. Lot Size: Fig. A. <br />................ ft. x .............. ft. — ............................... sq. ft. <br />s N <br />0 <br />N <br />0 3 <br />N •� <br />r•F <br />:`\aV <br />m <br />Z <br />(r`J <br />M C/) r- :PV.: <br />CD c m .Q-6 Ul rr <br />< C : <br />H <br />Z O O fD <br />o� N <br />V O � <br />/ O rr <br />..................................... ?..�� ��_ C <br />........ .... . . <br />0 <br />Signature of Ow r or Agent Date �* <br />„ x . <br />Remarks ��7%` �' `° p <br />./..................................................................................................................................................... m <br />................. <br />. ...... ...... <br />r <br />p <br />... .. ............... ... . ...................................... <br />Inspection Date ...G.......�. c.. . p o P. o m <br />Zoning Admin' rator o 0 0 o CCn <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 'o exist. Changes in plans or specifications shall not be made without approval of the Zoning Administrator. <br />SEWED' SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />