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x'99_ T-7 a,"/" <br /> Burnett County Office of Zoning Administrator 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMITW' 3 3 <br /> TO THE ZONING ADMINISTRATOR. The, undersigned hereby makes application for a Permit for the work described and located as < m <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the mquirernents of the Burnett County Land Usa <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> r' a <br /> Denis M. Simonsen <br /> . . .. . . . <br /> .......... <br /> OWNER Iplease print) CONT.. ......RACTOR or SU RVEV OR (',',–A"GENT m � m <br /> Rt....................Siren,...W?....54872.... ............ <br /> ................ ................................................................ a <br /> ADDRESS ADDRESS °± : r : D <br /> _ N <br /> ........................................................................................... .A......'R' 'E'S............................................................................... <br /> ADDRESS DDRES � I W <br /> 1 [oC1 3 <br /> 3.J. -.3?!.9._....2?91....................................................... <br /> PHONE PHONE <br /> ........Aon ]d...Dan.i.ell.................................................. ............................................................................ . ...... <br /> PLUMBER WELL DRILLER <br /> 73.ox...W.............uren.r...W.T....5.45.7.2...................... ................................................................................... . . o <br /> ADDRESSADDRESS (D <br /> m LD Z <br /> n o <br /> < <br /> 7.7.5-.463-2333....................................................... .......................................................................................... . 0 o <br /> PHONE PHONE z H <br /> r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms ....1.,... � ; <br /> 0 <br /> New Building .......... Type of Construction: No. Bedrooms .3....... :9J L <br /> Addition .......,,, Septic Tank Size Gals. ll ra: ' <br /> ....... ............................................ <br /> iii Q <br /> Sanitary ...X.... Size ft. x .............. ft. ......-�� ' m <br /> {hjni <br /> Filling .....__... Height............. Stories ............... 4a. Absorption Field Site: <br /> C: <br /> Moving .......... Area Soil Type .................................._ : £ r <br /> ..... ...... <br /> w o <br /> GradingSIoPe ................................... ...... :r <br /> .......... 'J :p, <br /> Mobile Home Perc. Rate .......................... <br /> 3. Use (describe exactly, 1 - family -- 1, o <br /> Privy .......... home,garage, motel, etc.) Dry Well ._....... :w <br /> Well .......... page Trench ...._.... <br /> Subdivision .....,,,.. Privy ..._..... ? 2L E ' <br /> .................................................... <br /> Seepage Bed 18x35 1u <br /> ______________.__—_----______-----_____---------__—__ --- W ion `. z <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc-, shou''d be sketched In Fig. A. Include roadr [s] <br /> setback, side and back yard dimension and location and setback from all bodies of water. If oroperty is located at a highway inter :7 a <br /> section, show the intersecting highways and the, setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> a <br /> STRUCTURES AND PROPOSED -- UC--- p <br /> AND ADDITIONS. ^ o' <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq.ft. ......................................................................................................... <br /> £ N <br /> w <br /> n <br /> N Q o <br /> o <br /> C Ew <br /> 0 <br /> 0 <br /> s <br /> m <br /> Z <br /> O <br /> ca: <br /> J] <br /> d <br /> m <br /> A W� <br /> M <br /> O 3 <br /> fA 3 <br /> � � <br /> ... .......... ....9....-.....Q.- " <br /> 0 <br /> S' nature of Own r or A eat Date X <br /> Remarks . 7�r.. ... :C.t:Zt'r .'. ........................................................................... .. T _ M <br /> ..... <br /> ...................... ............................................. .. .................. . <br /> lae <br /> Inspection Date - P tam <br /> (V <br /> . ................................. ...... .. ............. ...... ... ............ ............................ O O <br /> 000 o0m <br /> Zoning Admin rator 000 0 o (n <br /> y <br /> NOTE: A preliminary site Inspection must be made and site apptoval granted on Lill structures involving sanitary fac p�tics <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must he attach t to <br /> this application before a permit will be Issued. Do not purchase or install a septic tank, tlo any plumbing or stair any buil' <br /> ing until a permit has been issued. A permit may be revoked if misrepresentation of Lilly 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 Administlatol , <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />