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Burnett County Office of Zoning Administr for - <br /> 3 <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 o 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. - g <br /> .)toa............. ................. - <br /> 3 <br /> OWNER (plow print) _ CONTRACTOR or SURVEYOR or AGENT <br /> / . ` ..... . ....... ...I.......................... .................................................................................... ....... d —J <br /> ATr RESS ADDRESS $ <br /> ..,...f...1 �...... .... ............................. . . . ... .................................................................... .... ....... <br /> . <br /> ADOR SS ADDRESS ? ? n <br /> .......Q .G :-..(C .. ..` ..-:..'—��..`�:....................... .................................................................................... ....... C <br /> PHONE PHONE <br /> ix <br /> ........................................................................................... .WEE'"' 'L...L...DR........ <br /> ILL.E............................................................... ....... <br /> PLUMBER R <br /> ........................................................................................... .A..DDR..ES..... 'E'S"S.................................................................... ........ <br /> ADDRESS o <br /> n <br /> ............... . . .................................................................... .P..H..O..NE.................................................... _ <br /> ........................ ........ o <br /> PHONE ' <br /> Z ,^ r <br /> DESCRIPTION 4. Sanitary Facilities: P o » <br /> 1. Work: 2. New Building Details No. Bathrooms . ........ c <br /> New Building Type of Construction: No. Bedrooms . ........ <br /> Addition Septic Tank Size Gals. . ........ J <br /> .......... .................................................... i , <br /> Sanitary .......... Size .............. ft. x .............. ft. . ........ <br /> Flllingforeding .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ..................... Soil Type ........................... ........ <br /> ............... o S <br /> Mobile Home .......... Slope ................................. ........ » <br /> Privy 3. Use (describe exactly,-1 •family Perc. Rate .......................... ........ i <br /> Well home,garage,motel,etc.) Dry Well ..... z <br /> Subdivision .......... — Seepage Trench . ........ o <br /> ........ ... .. \1 .. ......................... . . .x <br /> Camping Unit .......... ........ I..Y... .... Privy ....... <br /> """' """' " Seepage Bed <br /> --------------------------------- <br /> Location <br /> ------------------ --Location of proposed structures and existing structures well sewage systems, roads, etc., should be sketched in F g. A. _ C <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is Ices led at L <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. ;� 0 <br /> ---------------------------------------------------------------- <br /> 5. Lot Size: Fig. 6. Location: � i � 9 <br /> ................ ft. x .............. ft. - ............................... sq.ft.t. ............ .. ..... . l..V..��.,.u,.. ........ <br /> . <br /> K <br /> 0 o <br /> 4 <br /> 9'�;;.� o <br /> Tj <br /> 70 [ <br /> 77 <br /> ) <br /> J Z <br /> ��� IJ�i lc1 l��ic5 a/Ca. P <br /> aMaas <br /> O C G <br /> CO J J ; <br /> Z <br /> ut= N n 9 <br /> a ; <br /> c o O� J . <br /> � C <br /> y ni m <br /> ........................................................................... ...................................... <br /> Signature of Owner or Agent Date 8 <br /> ' w <br /> T . <br /> m •• <br /> N <br /> .. ....................::... :.... . ........................ ...... ...... -I <br /> Inspection Date ....................................... ... .. '�).J.JlGG.�... ...: ..` ti.'. .�.. !!f.' �n rn rn o o a <br /> N m N N m <br /> Zoning Administr t r 8 8 8 8 88 (A <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary f icilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this apr lication 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 bei in issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans oi specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE ANDA PROVED. <br />