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Burnett County Office of Zoning Administrator d c o <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 o� :� <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use c <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. a <br /> ........... . ...... ..... .. F <br /> OWNER (please print) <br /> COCONTR OR or URV EVOR or AGENT m m <br /> ................................................................................ <br /> ADDRESS...... .ADDRESS... ...! .....s ...,3.................... a f\ <br /> = �V <br /> ........................................................................................... 'AD'D'R'E'SS.............................................................................. 0 <br /> ADDRESS <br /> ........................................................................................... ............................................................................................ <br /> PHONE PHONE \ <br /> ........................................................................................... <br /> PLUMBER WELL DRILLER <br /> ........................................................................................... <br /> ADDRESS . .......................................................................................... O ; •V <br /> ADDRESS <br /> o i <br /> . . . . .................................................................... .PHONE................................................................................ 0' - <br /> PHONE <br /> DESCRIPTION4. Sanitary Facilities: o. 0 o 0 <br /> 0 <br /> 1. Work: No. Bathrooms b <br /> 2. New Building Details ••••• • a: - <br /> New Building ..... .... Type of Construction: No. Bedrooms .......... F $ <br /> Addition ... ,,,,,• Septic Tank Size Gals. ~ <br /> .................................................... .......... m: < <br /> Sanitary .......... Size .............. ft. x .............. ft. ........ . i <br /> Pilling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: �fi E EJ <br /> Moving .......... Area ........................................... Soil Type .................................... r <br /> r' <br /> Mobile Home .......... Slope .......................................... <br /> Privy Perc. Rate ................................... u <br /> .......... 3. Use (describe exactly, 1 -family <br /> Well home,garage, motel, etc.) Dry Well .......... o <br /> Subdivision ✓•.,. Seepage Trench .......... t '• <br /> Camping Unit .......... .................................................... Privy Q o <br /> .......... <br /> .................................................... Seepage Bed <br /> ---------------------------------------------------------------------- <br /> Location of proposed structures and existing structures well, sewage systems, roads etc.,should be sketched in Fig A. Include road p <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 a <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 /> o' <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... <br /> N <br /> O_ j <br /> O <br /> O <br /> f <br /> a <br /> T <br /> Z <br /> m <br /> M <br /> n Q < m c o <br /> f <br /> -o <' <br /> m <br /> Z n o CD <br /> • es -'° 3 <br /> �il o <br /> y <br /> -02 7- �6 m <br /> ........................................................................... <br /> Signature of Owner or Agent Date <br /> X <br /> Remarksm ; m <br /> ......................................................................................................................................................................... :� p <br /> M <br /> ..................................................................................................... ... ................,�.vv//.// <br /> Inspection Date ....................................... .!N/C!:w./..:..........,... ..!xJ....""""./ ............................. ..... <br /> ............................... <br /> ................... <br /> ZoningAdministrator � . <br /> $ $ $ $ $ $ y <br /> NOTE: A preliminary site inspection must be matte 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 most he 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 the made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />