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Burnett County Office of Zoning Administrator iu o Z <br /> 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 < 0 '�'� <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use10 <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisco sin. 3 0. <br /> ......................... ....Brute.. cYnr�s........................................ �y <br /> OWNER (please print) ,l CONTRACTOR or SURVEYOR or AGENT <br /> A3. ...... .`I.......,....... ,re-sa.:................... ..R. .tA.....� X.. f�....................................... ...... <br /> CL <br /> AD FESS <br /> M. ls....... .M. ..N Ly"s�o.. ................................... �` ✓per l ��'y z- = �_ � � <br /> AD�ESS ......+""'. ...... . .........I.l...V..!.�..........' ...........l..V. .................... ...... <br /> ADDRESS <br /> 3 ' -5v i <br /> . .......... . ....7................�(....................................... ...... <br /> PHONE <br /> PHONE <br /> ........................................................................................... .WE......LL D......R.ILLER.....FIR' ............................................................ ...... <br /> PLUMBER <br /> ................................................................. ... <br /> ADDRESS ...................... .A....................... ....... .................................................... ...... — <br /> O <br /> DDRESS <br /> o <br /> . ...................................................................... .PHON.E.......... <br /> ............. <br /> ....... <br /> ......... <br /> ..... <br /> ........ <br /> ..................... ...... 017' <br /> PHONE <br /> DESCRIPTION 4. Sanitary Facilities: ° o 0 <br /> 1. Work: 2. New Building Details No. Bathrooms ... ...... <br /> New Building ✓ No. Bedrooms o <br /> ... Type of Con tru tion: ...... o '� <br /> Addition ...... „ ,,,,,(,(J,Q,(� , ,,,, Qh77C.., Septic Tank Size Gals. ... ...... J E <br /> Sanitary <br /> .......... Size ., ft. x .:. ..6.... ft. O <br /> FillingfGrading .......... Height............. Stories ..../........ 4a. Absorption Field Site: <br /> Moving .......... Area .................... Soil Type ............................. ...... .r <br /> o <br /> Mobile Home ......... Slope ............................ ...... ...... .. ; <br /> PrivyPerc. Rate ...........................I ...... 1 <br /> .......... 3. Use (describe exactly, 1 -family <br /> Well home,garage, motel, etc.) Dry Well ... ...... ~ <br /> Subdivision ,...,,.,. (,��Y�,p� �(o`�� Seepage Trench .,, ...... <br /> LJl ............................ �� <br /> Camping Unit .......... .................................................... Privy .. ....... <br /> —______— Seepage Bed .......... t� <br /> ____________ ______________ __ W: <br /> Location of ) � <br /> proposed structures and existing structures well, sewage systems, roads etc., should be sketched in Fig A. Include oad <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway i tter <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXIST NG 31 N.v p <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. (fir\1 - <br /> ---------------------------------------------------------------------- <br /> 5. Lo �S)3� q Fig. A. 6. L tali n: <br /> ...... ..fP... ft. x/lJ..0.... ft. — ... fR.•F•............... sq.ft. �d.Ye.Czeaj../.fail....................... ....., <br /> N <br /> o o <br /> 3 <br /> 0 <br /> O <br /> H <br /> I o \ <br /> d <br /> m <br /> X <br /> 3 4 <br /> rage. <br /> blN_. CILI <br /> a on < <br /> Z O O - n n <br /> l.� .�7.�.5?l�t....... <br /> Signature of Owner o gent ' Date <br /> v 1 <br /> X <br /> Remarks m m m <br /> ss - <br /> ......................................................................................................... .... ..... ........ .................................................. .. 1 . . . . <br /> Inspection Date ....................................... N m N <br /> . ....f.... . . . ... ............................................ <br /> Zo ' g Administrator 8 8 8 8 g <br /> NOTE: A prel'i ninary site inspection must be made and site approval granted on all structures inv Iving sanitary facillt �s <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 plum ting or start any build- <br /> ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the infortration conveyed here- <br /> with is found to exist. Changes in plans or specifications shall not be made without approval of the Zoning Adm inlstratoi. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />