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Burnett County Office of Zoning Administrator T0 0 <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 Z :� <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 O <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> :.. .. .... ...................................... .. ... ..... .. .................................. <br /> o O <br /> ' f <br /> J <br /> OWNER (please p ntl FyACTOR�aJ SURVEY R or AGENT n <br /> ........................................................................................... ............................................................................................ <br /> ADDRESS AD R SS <br /> - ...C. /.:....sy........ ............................. . <br /> ADDRESS ADDRESS <br /> ........... <br /> ....................:...................................................................... .P..HONE.............................................................................. <br /> PHONE <br /> ........................................................................................... . .....L DR......... ......................................................................... <br /> PLUMBER WEL.. -L-L' <br /> O <br /> . . . . .............................................................................. ............................................................................................ _. <br /> ADDRESS ADDRESS n o <br /> .............. <br /> ........................................................................................... 'P-i ........................................................................ n r1 <br /> PHONE PHONE Z <br /> DESCRIPTION 4. Sanitary Facilities: P o cr <br /> 1. Work: 2. New Building Details No. Bathrooms <br /> """"" o <br /> New Building .......... Type of Construction: No. Bedrooms .......... <br /> Addition .................................................... Septic Tank Size Gals. .......... <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... <br /> Filling/Grading •......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving ......:... Area ........................................... <br /> Soil Type .................................... <br /> Mobile Home .......... Slope .......................................... <br /> • o <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Well .......... home,garage, motel, etc.) Dry Well .......... <br /> subdivisionSeepage Trench .......... <br /> L .................................................... <br /> Camping UnitPrivy .......... <br /> .......... .................................................... <br /> Seepage Bed .......... <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc., should be sketched in Fig. A. Include road Q <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- o: <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. <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location <br /> i <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... 01 <br /> : ((-- <br /> t 0` <br /> 0. <br /> IN <br /> W <br /> /� > 711> <br /> I I o <br /> D, 0 V J <br /> l Uj a <br /> T <br /> 0- <br /> L <br /> Z <br /> O <br /> 77 <br /> d <br /> J <br /> b <br /> N <br /> C) <br /> (�/1 <br /> c m <br /> n fprn < '° � F <br /> c = n <br /> (NII `' u : ,< m m <br /> _ m <br /> Z o D a <br /> o20 : n ' <br /> 6S m 3 <br /> ......................................................... 9...:3.'.........-......... �o C <br /> Signature of Owner or Agent Date <br /> X <br /> T <br /> Remarks ......................................................................................................................................................................... m„ � <br /> m <br /> ........................................................................................................................................................................................ U m <br /> it <br /> Inspection Date ....................................... . ........... ......... ...................... i ° �Q 0 8 0 ,u�r m <br /> Zoning Admi istrator � � : I 8 8 8 8 8 8 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 tfe made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />