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l,�i 6 Cc• �n l'U 4� <br /> lgtmty Office of Zoning Administrator 'gi <br /> -APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT � 3• 3 ; <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 i$ c <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws nd 3 !-�— <br /> regul ions of the State f Wi onsin. » •Y <br /> ..G...G..I............ '� `�. p..r.............................. ......................................................... ...... n <br /> OWNS�ER Iplease printf � ((Q CONTRACTOR or SURVEYOR or AGENT <br /> ......l...r��pv4 ........ .......... <br /> ..�..........S.q1 .3... ..................................................................................... ...... <br /> ADDRESS ADOR ESS = I <br /> ......9.b......................................... ..................................................................................... <br /> ADDRESS +�Q/� y��,�r—, ADDRESS <br /> PHONE......rjlF.1. .•4X••/��.......................................... .PHONE......................................................................... ...... <br /> :QC <br /> Rp <br /> ....�dr°.�.:.``...................................................... ..................................................................................... ...... '9 � <br /> PLUMBER WELL DRILLER <br /> ADDRESSADRESS 0 C :4 <br /> D <br /> G w <br /> ........................................................................................... ... ........................................................................... ....... <br /> :1 <br /> PHONE PHON......E 0 H r <br /> DESCRIPTION 4. Sanitary Facilities: ° c °» <br /> :Cj o <br /> 1. Work: 2. New BuildingDetails No. Bathrooms .. ....... R <br /> : <br /> New Building Type of Construe ' q: No. Bedrooms .. ....... <br /> Addition ......... ..... ....•... Septic Tank Size Gals. �4 <br /> Sanitary ...)e Size ............ . ft. x .............. ft. � •�)o <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> g Soil Type ............................ ....... ' r- <br /> Movin .......... Area ......................................... O <br /> Mobile Home ...... Slope .................................. ....... <br /> .... <br /> .. <br /> Privy ,.,....... 3. Use (describe exactly, -family Perc. Rate ........................... ....... 'o <br /> m <br /> Well Dry Well <br /> ,,,,...... home,garage,motel, etc.) <br /> Seepage Trench Z •`� <br /> Subdivision .......... ... ................................ .. .... :W <br /> Camping Unit Privy o ..,.� <br /> Seepage Bed .. ....... <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. :VI c <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at :QJ _ <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersec ion. :Q) <br /> CLEARLY LABEL EXISTING_STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. _ __ : S (/nA <br /> 5. Lot Size Fig. A. 6 Location <br /> ...... ... ..... ft. x ......... ft. ............................... sq. ft. .............. ..... ................................... ........ <br /> N O <br /> O ] <br /> ] <br /> o V <br /> O <br /> f <br /> iup <br /> J <br /> S <br /> O <br /> T <br /> m <br /> 0 <br /> O <br /> D <br /> d <br /> m <br /> m c M U r > m: 1.+ <br /> A n �o < JJn — — fn <br /> (�, m moo.•< o. m nn y <br /> O m < N O aJ O <br /> NJ : Nn <br /> rn <br /> 'v........ ' O <br /> Signature of ner or Agent Date <br /> Remarks m a <br /> m. ,. <br /> � 8 <br /> ........................................................................................................... ... ...................... . .......... ............................. ...... <br /> Inspection Date r• N N J J N m <br /> ....................................... ........ .../..:..... ... ... . vt vt o Ppm <br /> Zoning Administr r c7/rl -! 8 8 8 8 8 y <br /> NOTE: A preliminary site inspection must be made and site appro 1 granted on all structures involving sanitary f cilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this ap lication 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 be n issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans oi specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE ANDA PROVED. <br />