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Burnett County Office of Zoning Administr for W T 'f <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT . <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 rte , <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and d <br /> regulati'Qnso the St to of Wi consin. 3. <br /> �..�.c..... ..s..... . ..r....s. ....................... ..Se.I.F.:........................................................... ...... <br /> OWNE (please print) CONTRACTOR or SURVEYOR or AGENT V , <br /> .......... .135.....JJ.Y..Ar.ei...U.�:.(......... ................ .................................................................................. ...... d <br /> ADDRE 71. J ADDRESS <br /> ....... <br /> ADD . <br /> ADDRESS............................................................................ ...... <br /> i <br /> PHONE....!.. . l.... . ..... ..1.. ..................................... .PHONE......................................................................... ...... O'+ <br /> ........................................................................................... <br /> W <br /> PLUMBER .E. ...... ..RILLER.. ...... .............................................................. ...... <br /> LL D <br /> .............................................. ................................... <br /> ..... ..... .O <br /> ADDRESS . ................................................................................... ...... � �� . <br /> ADDRESS <br /> O <br /> ........................................................................................... =� �• <br /> PHONE ...................................................Y................................ ...... ,• <br /> PHONE Z H <br /> DESCRIPTION r <br /> 4. Sanitar Facilities: ° o ° • <br /> t. Work: 2. New Building Details No. Bathrooms ... ...... i � / <br /> o <br /> New Building ... ... Type of�°nstruction: No. Bedrooms ... ...... i <br /> Addition .......... ...........f.�:IiI n,4......................... Septic Tank Size Gals. ... ...... < V <br /> Sanitary .......... Size .......;L.Y. ft. x .....��.... ft. ... ...... � i <br /> Filling/Gradinga. Absorption ed Site: <br /> .......... Height...�.�.p..... Stories ............... 4AbiFilS <br /> Moving .......... Area ..........F+..(P t/ Soil Type ............................. ...... i i r <br /> ... .......... ............ <br /> o <br /> Mobile Home .......... Slope ................................... ...... : .. <br /> Privy Perc. Rate .........................I.. ...... m <br /> .......... 3. Use (describe exactly, 1 -family 0 i <br /> Well .......... home,garage,motel, etc.) Dry Well ... ...... m <br /> Subdivision q R Seepage Trench z <br /> Y.... ... ...... . <br /> . ...................... <br /> Camping Unit .......... �..... Privy . <br /> Seepage Bed .- <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 backyard 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. o <br /> -- <br /> ------------------ <br /> 5. Lot Size: <br /> Fig. A. 6. Location: <br /> t. ^ <br /> N 0 <br /> '. <br /> 0 <br /> O 70 <br /> 10 <br /> � <br /> -vmrD W co -0 <br /> SLtVF�C > no v < on 00 E E m <br /> m 0 Ei. <br /> � N _ <br /> O HO '2 D� 1 <br /> u eza ' <br /> n ; y <br /> o <br /> 0M <br /> ( IFS » on : c <br /> m <br /> .... A <br /> rn <br /> Signature of Owner or Agent ja�t o <br /> o . <br /> y <br /> Remarks 0 <br /> ........................................................................................................ ............................ .. . ...................... ... <br /> Inspection Date ....................................... .. . . . .r.. .. ......... .. <br /> Zoning AdministrY� $ $ $ $ $ <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary fac lities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this appli ation 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 s ecifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APP OVED. <br />