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Burnett County Office of Zoning AdministratorC o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 3 <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes applicaton for a Permit for the work described and located as < m <br /> shown herein, The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m c <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin_ a <br /> L G . 76)" ... µ <br /> Cc <br /> .............. <br /> :... ......... ... ..................................... . .............................. . ..... N ono <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT m ; <br /> f'T.r.......� ......................................... ..............................................................I.................... . <br /> ADDRESS ADDRESS <br /> m 1 <br /> (�I Ii.S.x.cJ2 <br /> .............W-f.. ........,�5./ <br /> ADDRESS ADDRESS <br /> ...... .............................. ................................... ...... ....... .....O...NE....... .............. .... ............. ....... .......... <br /> .��............V. .. ..................... <br /> 00 <br /> PHONLE ('1 w' PH <br /> .. ` c lfle f�...................... ........ ............................................................................................ :^^ <br /> PL.C.UMBER WELL DRILLER' <br /> ADDRESS . . . .......................................................................................... m C) <br /> ADDRESS <br /> o <br /> ..........2 .s-..63.s-,7.>.S�tl....................................... ° <br /> PHONE ............................................................................................ Z0 <br /> PHONE <br /> DESCRIPTIONr <br /> 4. Sanitary Facilities: <br /> 1. Work: 2. New Building Details No. Bathrooms .......... <br /> New BuildingNo. Bedrooms <br /> Type of Construction:" L 1 <br /> Addition „ ,..,,... Septic Tank Size Gals. /.1"0 <br /> ......................... ...................... <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... <br /> Filling/Grading .......... Height........... Stories ............... 4a. Absorption Field Site: <br /> Moving Area .. Soil Type ......rl71”.................... o <br /> .......... ..................................... ... ,Y <br /> Mobile Home .......... Slope ...........w2............................ 1 <br /> Pere. Rate .........../ <br /> ..................... 1 <br /> Privy .,,,.,,.., 3. Use describe exactly, 1 -family <br /> Well ,,, home,garage, motel, etc.) Dry Well .......... w � <br /> Subdivision .,.,, ,,,. Seepage Trench .......... i <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- Include r� .° <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- [ a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEASLV LABEL EXISTING <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> o' <br /> 5. Lot Size: Fig. A. 6. Location: r <br /> as <br /> ft. x .............. ft. . ............................... sq.ft. ............................................................................... <br /> h <br /> u <br /> a <br /> N o o <br /> O <br /> See QtkachPd( <br /> 0 <br /> ° <br /> s <br /> T <br /> Im <br /> V � <br /> 1 f�ti. <br /> 1V <br /> 7J N 9 NJWZ <br /> c N <br /> IT1 < C : `G (O C IT <br /> A. Z O O D n T <br /> 0 v ° _a m <br /> as <br /> / _ <br /> ................ . �o <br /> Signature of Owner orAgentDate �''��� �c <br /> Remarks .f(i' ..GCJ'Zl'¢:'n'......s.... .......................... M1...a......""'"'" ' IT <br /> ".�`..................................................... E IT <br /> G. ...... ....... ...... ................. ... .................................. aa <br /> ............................ ....... ............................................. .... ::. <br /> •7 p e"r01 <br /> Inspection Date ..............��. ::a.. ..... .. ..... ..a..:.....7 m <br /> �n <br /> Zoning AdminiStAtorfi i i $ $ $ $ fA <br /> NOTE: A preliminary site inspection must be made and site approval granted on all Structures involving sanitary facilities <br /> y before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be ettached 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 be made Without approval of the Zoning Administrator_ <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />