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Burnett County Office of Zoning Administrator 6' 7 <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 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the ,$ <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and <br /> regulations of the State of Wisconsin. �(�� _ <br /> Rl.� C�! G� .. �4vs.S1..?S# ...................... <br /> ^ . ................ . <br /> OWNER (ptaue print) .......... <br /> CONTRACTOR or <br /> >" n <br /> SURVEYOR or AGENT �" a <br /> . .!.�iJ.II. ...I.................................................................. .ADDRESS............................................................................ d � <br /> AIR ESS ��n <br /> .. l..rp!.i.�ilA. . ... .r....�:I4k........................... .ADDRESS............................................................................ i� n <br /> ADDRESS l� <br /> PHONE......................... . . . . .................................................................................... <br /> PHONE <br /> ......................................... ... <br /> .. ............................................. . . ..................................................................................... <br /> PLUMBER WELL DRILLER <br /> ADDRESS............................................................................ . . ...... . ............................................................................... IO <br /> ADDRESS <br /> ~ O <br /> . . .................................................................... .PHONE................................................................................ 0 <br /> PHONE .^ <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms ` V : :T <br /> 2. New Building Details ......•• c 0New Building ,,,,----„ Type of Construction: No. Bedrooms .......... R <br /> AdditionSeptic Tank Size Gals. .......... <br /> .......... <br /> SanitarY .......... Size .............. ft. x .............. ft. .......... <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: i <br /> Moving .. .. Area ........................................... Soil Type .................................... � <br /> p <br /> Mobile Home ... . ... Sloe ...................................... ... o <br /> v <br /> Privy .......... I Use (describe exactly,*1 -family erc. Rate ................................... <br /> m <br /> Well .......... home,garage, motel, etc.) Dry Well .......... m i <br /> Subdivision .....,,,,, Seepage Trench .......... Z <br /> .................................................... <br /> Camping Unit .......... Privy <br /> ------------------- Seepage Bed .......... i Z <br /> ------------------------------- N m <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc. should be sketched in Fig. A. c <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. -� < <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. I <br /> 0 <br /> ----e: --- — -------9--- __ <br /> ----------- C) <br /> 5. Lot Size: `"f-lJ ( Fi A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... , \` <br /> 6 <br /> ° <br /> N <br /> O �° <br /> o :W <br /> o <br /> V f <br /> l 1�1 <br /> T \V <br /> Z :L <br /> O <br /> a <br /> J <br /> m <br /> � rnvrnrDwm � <br /> Via < > > n EE In <br /> a N a <br /> C m a n <br /> p m 0 5 3 <br /> ° mom <br /> Nom ' ya ' <br /> o . a : y <br /> 0 <br /> n o O <br /> C <br /> S <br /> ..ignature...... .. ...o. . . ..f...... . ... ......ntat................................. ................D.Data................ <br /> Ow..ner.. ..or..Age � a " O <br /> o : <br /> o , <br /> Remarks m <br /> o : o <br /> .......................................................................................................... ....................... .. ....................... c o <br /> Inspection Date ....................................... ... :+T/JYCl/...Y...:..... t�!1 <br /> Zoning g g o o N <br /> NOTE: A preliminary site inspection must be made and site ap roval granted on all structures involving sanitary facilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this application 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 been issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />