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&9 22Ce'),v <br /> Burnett County Office of Zoning Administrator - <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 • 'Z : NiLJ <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 3 <br /> regulatyp of t e tate of Wiscon <br /> � ... rs....9 ... t... r..aur ... . . n <br /> OWNER (please rind O TRACTOR or SURVEYOR or AGENT <br /> y O <br /> G <br /> ADDRESS..... .... ................................................................. .ADDRESS............................................................................ n <br /> ...I?T-.../Y........ ..............................I............ ............................................................................................ rb <br /> ADDRESS ADDRESS I ?� <br /> Gl esr : <br /> PHONE ..t....C)<s: ................ . . . ...................................................................................... <br /> PHONE <br /> ...........3..y.9......z.3ys........................ .WELL...........DRILLER. .............................................................................. <br /> PLUMBER <br /> ADDRESS ADDRESS n o+�:r� <br /> c <br /> ........................................................................................... ............................................................................................ O .+ <br /> PHONE PHONE Z N r <br /> DESCRIPTION 4. Sanitary Facilities: P o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details c <br /> New Building .......... Type of Construction: No. Bedrooms .......... •• (� <br /> Addition .................................................... Septic Tank Size Gals. .......... E V 1 <br /> .......... <br /> Sanitary Size .............. ft. x .............. ft. ....... <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... <br /> o <br /> Mobile Home .......... Slope .......................................... � .. <br /> Privy ,,,,,,,,., 3. Use (describe exactly,'1 -family Perc. Rate ................................... d <br /> � <br /> Well .......... home,garage,motel, etc.) Dry Well .......... <br /> he Tren <br /> Seepage Subdivision Seeo <br /> •'•••••••• <br /> Camping Unit .................................................... Privy .......... <br /> Seepage Bed <br /> .......... ice: I <br /> ---------------------------------------------------------------------- <br /> C <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. F <br /> Include road setback,side and back yard 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. : 0 <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: i <br /> ................ ft. x .............. ft. — .................... sq.ft. ............................................................................... <br /> N O <br /> O J <br /> J .^ <br /> J ,VI``ll <br /> O LW <br /> O <br /> 7Z3 0 <br /> r i3 <br /> 0 <br /> Z <br /> p <br /> p <br /> J <br /> � <br /> o N�a < J o -. -. m <br /> m n•c nm any <br /> Zy^,o > : 1 <br /> v,J m a . S <br /> a m <br /> Signature of Owner or Agent Date ro <br /> Remarks � n <br /> ........................................................................................................................................................................................ <br /> ............................................................................................................. ..... ................. , <br /> Inspection Date ....................................... r ... f .Y..'.<Ah. ........ e N (ml, fNT O N m <br /> . . .... .. ... . m <br /> Zoning Administrat ra•• <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 />