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V <br />Burgett .County Office of Zoning Administrator <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 <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. <br />Q.. ........ ►... ' . 5..........................�. L.... ....................................................... <br />O E (please print) CONTRACTOR or SURVEYOR or AGENT <br />. .....ie-.. ..,............... x a.......................................................................................................... <br />ASS ADDRESS <br />AD RES a3 / 7 ADDRESS <br />....v^..............................................................PHONE .......... <br />...................................................... <br />PHONE <br />............................................... <br />PLUMBER WELL DRILLER <br />................................................................. .......ADDRES—EIS—S................... <br />ADDRESS <br />PHONE PHONE <br />DESCRIPTION <br />1. Work: 2. New Building Details <br />New Building...Type tructi <br />....... <br />Addition ......!!.1. ..... ............ <br />4. Sanitary Facilities: <br />No. Bathrooms ...I ' <br />..... <br />No. Bedrooms <br />Septic Tank Size Gals. <br />Sanitary .......... Size `.. �t. x .J..... ft. <br />.P . <br />Filling/Grading .......... Height ..I ....... v. Stories .... t.......... <br />......... <br />4a. Absorption Field Site: <br />Moving Area <br />Soil Type ................................... <br />Mobile Home <br />Slope ......................................... <br />PrivyPerc. <br />.......... 3. Use (describe exactly, 1 - family <br />Rate .................................. <br />Well ho ,garage motel, etc.) <br />Subdivision ......... pp <br />�� /C© <br />Dry Well ......... <br />Seepage Trench ......... <br />.... ............... <br />Camping Unit .................................................... <br />Privy <br />---------------------------------------------------------------------- <br />Seepage Bed <br />Location of proposed structures and existing structures, well, sewage systems, roads, etc., <br />should be sketched in Fig. A. Include road <br />setback, side and back yard dimension and location and setback from all bodies of water. <br />If property is located at a highway inter <br />section, show the intersecting highways and the setbacks required along them and at the <br />intersection. CLEARLY LABEL EXISTING <br />STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br />------------- -------------------------- <br />5. Lot Size: Fig. A. 6. Location: <br />................ ft. x .............. ft. — ............................... sq. ft............................................................................... <br />Im <br />dpb <br />i <br />Z <br />° 0 <br />3 3 <br />o <br />C N { ^\ <br />3C v\ <br />;7+* <br />°OC \ <br />N � G <br />co <br />N r•h ' <br />y <br />D <br />CD G7 <br />h o <br />< <br />o' <br />Z <br />0 0 0 <br />0 <br />Z <br />CD <br />o <br />w <br />"1 <br />N <br />C: ?� <br />1 Q <br />T <br />0 <br />Ut i <br />A <br />(D <br />N 0 <br />o <br />o �1 <br />4 -n <br />CD :l <br />z <br />0 <br />n: <br />cc <br />CD <br />:C <br />�p Cn r v cn Co z <br />CD on v <br />CD <br />cn En a a < _ ' a <br />CNTr < H <br />Z oo' : D a <br />CD <br />-M <br />�» aU <br />0 . . . . <br />70 <br />T <br />1......... . .... ........QJ.. :� <br />M <br />p <br />�ignatu e of Owner or Age t J Date ° C <br />Remarks ..%Y ...... �a?'t..4�©►vv'y�" 1... ....r� � u,......� uc.:�.... i..... w��!.....b��c!hoa�+....ai,:C�Gt.�'G ..•..!% X : v <br />CD <br />�� �.:.. e . Si'?✓'1• /fir ...... ` �.../ .....4........�r.......... <br />G <br />................................. ...... ... . . . . . . <br />Inspection Date ....................................... Zoning Aator 0 0 0 m <br />o N <br />JOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br />)efore 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 riot 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 he made without approval of the Zoning Administrator. <br />SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />