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Burnett County Office of Zoning Administrator lip q�q <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT <br /> ° ca0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and <br /> reguationsof the Stateof WiSC046'" 3' a <br /> !..Y.C.............. °.1...1..x(.. d.. .......... 4!...1.. ers...... a <br /> y- ........................ �i.. <br /> OW ER (pleas print) / CONTRACTOR or SNRVEYOR or AGENT <br /> C <br /> �.j..,..... �� ............... .� <br /> ............................................................................................ d f <br /> ADD ADDRESS m . , .t Al <br /> ..1. ts <br /> ....................................................................... . ...... . . ............................................................................... , <br /> ADDRESS ADDRESS i� :"C <br /> .... ... ...... .......................................................................... ............................................................................................ <br /> PHOE PHONE <br /> x.}...� ..... .......... ........................................................ .............. <br /> PLUMBER WELL DRILLER <br /> v 1 <br /> .............. <br /> . . . ................................................................................ .AD......D.....RES.................................................................. n ° <br /> ADDRESS S 'm L7 :� <br /> ........................................................................................... ...................................................Y....................................... .rC <br /> PHONE PHONE Z N r- <br /> 4. <br /> :[� <br /> DESCRIPTION 4. Sanitary Facilities: ° o `� <br /> 1. Work: No. Bathrooms ... .. <br /> `! 2. New Building Details ?� 'o <br /> New Building ...)(.. TypqAf Construction: No. Bedrooms .......... ?� <br /> Addition ... ...... .......IS,.. /1Q•!'!!t,�-.'t.................... Septic Tank Size Gals. .......... <br /> Sanitary .. .... Size ... .�+.. yft. x ...5.�... ft. /......... <br /> Filling/Grading ,.,,,,.,,. Height !.�'.K Steorlas �.c C(�• 4a. Absorption Field Site: <br /> Moana Area ;:6.X. 0 9 ��.Ht. ,'•ie Soil Type .................................... 0 i <br /> Mobile Home ........ . .......�.' Slope .......................................... » <br /> .......... <br /> Privy 3. Use (describe exactly, - it Perc. Rate ................................... <br /> Well • Dry Well """"" m.... .. home,garage,motel, etc.) )Subdivision STh o <br /> .......... Seepage Trench .......... <br /> .................................................... Privy <br /> CampingUnit .......... .................................................... V <br /> Seepage Bed 11G3.,A :� ` '• <br /> ------------------------------------------------------------------ I <br /> CA <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. c <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at FL <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. % : `- <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> ___ _________________ ______ ________________ �.,� i <br /> 5. Lot Size: Fig. A. 6. Location: i <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... <br /> Ivt <br /> 0 '\ o. <br /> 0 <br /> o <br /> f <br /> 9 � <br /> U � <br /> : I <br /> b <br /> T <br /> 0 <br /> O <br /> 9 <br /> v <br /> e <br /> m <br /> N c M d N tDi Up C3 -0 <br /> LD �a� 0 a a <br /> oo< , dcyo5 .= <br /> p <br /> 0 > ' i <br /> » e : s <br /> 8 ao m <br /> 0 J o <br /> xA <br /> m <br /> 0 <br /> m — <br /> Si natur f Owner or Agent Date o <br /> Remarks .. ��......�....C. .::�...!..`.:-. Ti <br /> ......./ .... . ............................................................................................................. m_ <br /> m •• <br /> m <br /> o : 8 <br /> .......................................//....TT..........T................................................ . ........... <br /> N 8OJ <br /> N r r Nrj m <br /> Inspection Date ...... 1 .. .. : .�............................ m....... ....... . ... <br /> Zoning <br /> Administrator 8888880 <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this application 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 been issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />