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r- <br /> Burnett County Office of Zoning Administrator 9 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT = 3 <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 al I work shall be done in accordance with the requirements of the Burnett County Land Use m m <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> myg <br /> John Henthorne O <br /> N c <br /> .. .. ........................................................................... ............................................................. H v Q < <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT a 14, M <br /> Rt. 2 Box 1125 Siren, WI 54872 <br /> ADDRESS ADDRESS � tp <br /> ........................................................................................... ............................................................................................ <br /> ADDRESS ADDRESS <br /> .................. . ........................................................ <br /> ............ <br /> PHONE PHONE ; Ct <br /> Donald Daniels ............ ;C r\ '• <br /> PLUMBER WELL DRILLER : ' <br /> Box w Siren, WI 54872 _v <br /> ................................................... .. ......................................................................................... `° <br /> ADDRESS A.DDRESS i� � O <br /> w � <br /> ........................................................................................... ............................................................................................ o• .: <br /> PHONE PHONE z y r. <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms ....1 <br /> o <br /> New Building Type of Construction: No. Bedrooms ....3..... t a <br /> Addition Septic Tank Size Gals. ; < fu <br /> ............... ................ 1 bib... :v <br /> Sanitary .....g... Size .............. ft. x .............. ft. ••• <br /> Filling .......... Height............. Stories ............... 4a. Absorption Field Site: k <br /> Moving ............Soil Ter <br /> Slope ............................1% O <br /> Grading <br /> K <br /> Mobile Home Pere. Rate ...................... <br /> 3. Use (describe exactly, 1 -family 3•••••••••••• <br /> Dry Well .......... I :W <br /> Privy ........., home,garage,motel, etc.) Seepage Trench i <br /> Well ....X... ...........Mobile••homne............... Privy .......... <br /> Subdivision <br /> ................................................... Seepage Bed <br /> ------------------------------------------------------------------- -- <br /> Ln <br /> Lobation of proposed structures and existing structures,well,sewage systems,roads,etc., should be sketched in Fig. A. Include road + C <br /> Q <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway interCL <br /> - <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING y •N <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. - o' <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... <br /> m <br /> n <br /> N o <br /> o <br /> 3 <br /> O <br /> Ni <br /> O <br /> 7 <br /> N <br /> -n :W <br /> z <br /> Z <br /> 0 <br /> rn <br /> m <br /> (nr � tncoz <br /> C d <br /> T. fft <br /> a Ut< O : ;' O <O � <br /> O E:N : -G ` m <br /> Z <br /> O O o m <br /> 017 <br /> Ml <br /> O <br /> iJ a <br /> Signature of Owner or Agent Date — <br /> X <br /> Remarks ......................................................................................................................................................................... -n 6 E i E m <br /> v <br /> ........................................ :p <br /> ............................................................................................................. . ............. 'o _4A <br /> O - r dr M <br /> N <br /> TI <br /> Inspection Date .....:................................. . .....:.. i o 0 0 o o m <br /> Zoning Ad inistrator 0 0 0 o o to <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 />