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Burnett County Office of Zoning Administrator fC c <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 •2 p <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the n <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. 3. Q. <br /> .............../. =R............. ............................................................................................ <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT <br /> R. . €...... ............................................................. ............................................................................................ d : <br /> AVO <br /> . V ................. .ADDRESS T— <br /> m <br /> DDD ........................................................................................... <br /> AD RESS ' ADDRESS <br /> ............ 1.G. .......g5.. . T.................................. ............................................................................................ <br /> PHONEa <br /> ..................................... PHONE <br /> . . . ... . . ................................ . . . ..................................................................................... <br /> PLUMBER WELL DRILLER <br /> ........................................................................................... .AD......D.....RES................................................................................ <br /> o <br /> ADDRESS S n <br /> ........................................................................................... . . .................................................................................. o .' <br /> PHONE PHONE...... .. Z <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details ••••••"•' ` 'o <br /> New Building . • •• No. Bedrooms .......... <br /> •......... Type of Construction: <br /> RI Tt <br /> Addition <br /> Septic Tank Size Gals. .......... <br /> Sanitary .......... Size ..../.�... ft. x ..�,.ry:.. ft,., .......... - <br /> Filling/Grading .......... Height...*....... Stories ....1.......... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... <br /> Soil Type .................................... i r- <br /> 0 <br /> Mobile Home .......... Slope .......................................... ^ <br /> Privy ...,,,,,,, 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> m <br /> weft .......... home,garage,motel, etc.) Dry Well .......... <br /> Seepage Trench z <br /> Subdivision .......... .... .. .. .......... o . <br /> Camping Unit .�S.LCrA�.. . nn . .. Privy .......... <br /> .......... K ............ . <br /> Seepage Bedt ' <br /> Location of proposed structures and existing structures well sewage systems, roads, etc., should be sketched in Fig. A .9 .g <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at .w - <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. :CJ i o <br /> __ In i J <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . .................... sq.ft. ............................................................................... <br /> N O <br /> ' j <br /> 0 <br /> p <br /> r <br /> z <br /> 0 <br /> f �/O <br /> osF <br /> d00JJ ; <br /> a y <br /> 0 D <br /> � '� � .............. :..1... .%�7 x p <br /> M <br /> Signature of Owner or Agent Date <br /> 8 : <br /> j <br /> N . <br /> Remarks ......................................................................................................................................................................... m <br /> m .. <br /> Inspection Date ....................................... ...`FCCG92C .... . .. � v m <br /> a -� N <br /> .................. . . .. .. ............. <br /> Zoning Admi i trator 8 8 S S 8 W <br /> NOTE: A preliminary site inspection must be made and site approval 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 />