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C 1 <br /> Burnett County Office of Zoning Administrator �n 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — G ILDING PERMIT 3. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR'. The undersigned hereby makes application for a Per It for the work described and located as < — :u <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use -C' c <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br />..Ca� 44ni ..... ..../ .......... ................................ .... ...... !.r' . .C-' .................................... C _ O <br /> a <br /> OWNER (please prin <br /> CONTRA OR or SUR VEjV OR or AGENT a <br /> .................... �.1.. .�... >�J.?X.7�......................................... a <br /> ADDRESS AD f °i <br /> w ........ ...................... <br /> ADDRESS ADDR,ESS .... <br /> ............................................................................................ <br /> PHONE. ............................................................................... WELL PHONE <br /> ... . .. . ....................................................................... <br /> PLUMBER DRILLER <br /> .................................................................................... .ADDRESS—D'C.................. ... <br /> .. ........................... ... <br /> .-........ ...................... <br /> ADDRESS <br /> D o <br /> . . .................................................................... . . . . ................................................................................... <br /> PHONE PHONE Z � ' <br /> r <br /> 4 <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms <br /> New Building Type of Construction: No. Bedrooms .......... �( <br /> Addition .......... ..................................I................. <br /> Septic Tank Size Gals. .......... <br /> Sanitary .......... Size .............. ft. x ft. .......... <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Soil Type .......................... <br /> .......... ........................................... .......... r <br /> Mobile Home .......... Slope .......................................... o.. <br /> Privy Pere. Rate ................................... i <br /> .......... 3. Use (describe exactly, 1 -family Dry Well <br /> Well .......... home,garage, motel, etc.) .....••.•• r <br /> Subdivision ... Seepage Trench .......... L <br /> Camping Unit ,,, Privy ......... i <br /> .................................................... Seepage Bed <br /> .......... r <br /> ---- ---------------------------- ----- <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig. A. Include road —} <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- I a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING < a <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> o--------------------------------------- -------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — sq. ft. 111, <br /> N <br /> m <br /> O <br /> 0 <br /> : <br /> m \ <br /> Z <br /> 0 <br /> v <br /> m <br /> VI <br /> rm N m Z <br /> N a C . v m <br /> Z oo Dn <br /> 0 <br />........................................................................... o <br /> �- <br /> it o m <br /> .. ..... ..... o [ C <br /> Signature of Owner or Agent - Date <br /> X <br /> Remarks ......................................................................................................................................................................... T . . . . . . m <br /> m <br /> O <br />........................................................................................................................................................................................ `E`<r�. <br /> :W II <br />........................................................................................................ .. <br /> p : �E41 - N - m � Nm <br /> ... ....... ... ........... <br /> .. ...... ............. . ................. <br /> Inspection Date ....................................... ..Gr1 .9../..:..... ............. ............ .... :C o U o v, o u, <br /> ir-✓........... o m <br /> Zoning Administrator : : lu o g o g $ o y <br /> DOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilitles <br /> tefore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> his application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build <br /> - <br /> ng until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here <br /> - <br /> vith 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 />