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Burnett County Office of Zoning Administrator 0 � o 0 <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 located as ._, � :l <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use c <br /> Ordinance, Sanitation Code, <br /> Code, and with all other applicable County Ordiin(annceess and the laws and regulations of the State of Wisconsin. 3 d � <br /> C, \//W h�R/a s GUln+A-d7✓ — m 0 <br /> . ........................ .... ....................................... . . . . . . . . ............................................................. r. <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT m <br /> ......................... .fir....�.......e..... ......ss P.y.:3................................. <br /> ADDRESS ADDRESS .. <br /> ADDRESS <br /> ADDRESS <br /> ............ <br /> ........................................................................................... ............................................................................. ... <br /> PHONE PHONE <br /> ........................................................................................... ............................................................................................ <br /> PLUMBER WELL DRILLER <br /> ........................................................................................... ............................................................................................ <br /> ADDRESS ADDRESS <br /> n o <br /> ........................................................................................... ............................................................................................ o .: <br /> PHONE PHONE Z17 <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms .......... o <br /> New Building ,,,,,,-.,, Type of Construction: No. Bedrooms .......... <br /> Addition .......... .................................................... Septic Tank Size Gals. .......... <br /> Sanitary .......... Size .............. ft. x ft. .......... <br /> Filling/Grading ,,,,,,,,,, Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Area Soil Type .................................... r <br /> .......................................... <br /> o <br /> Mobile Home ......... Slope ..................................... .... 0 <br /> Privy Perc. Rate ................................... <br /> .......... 3. Use (describe exactly, 1 -family <br /> well ,, home,garage, motel, etc.) Dry Well .......... o <br /> Subdivision ..... <br /> Seepage Trench .......... >v <br /> Camping Unit .......... Privy .......... <br /> .................................................... Seepage Bed <br /> .......... :Y <br /> --------------------------------------------------------------- ------- <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road Q <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- o- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> P <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> ------------------------------------ ----------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . �../....<..../.y..�............ sq.ft. ............................................................................... Orr m <br /> N O <br /> doh II ��0.,5161- 1�3 0 <br /> — _ t <br /> �-r ;it <br /> �I O <br /> 7J <br /> j <br /> aiaC� m = cv <br /> — m <br /> z ooa <br /> o n am _3 <br /> Fn a — <br /> U.ro <br /> E1Jo m <br /> 0 <br /> ........................................................................... ...................................... o C <br /> Signature of Owner or Agent Date <br /> X 70 <br /> Remarks ......................................................................................................................................................................... m :� m <br /> v <br /> ....................................................................................................... . ......................... .. ..... ................................I....... ` <br /> Inspection Date ....................................... Q !? .2.....:......�,�.. . .a..Q.�.??�...... .............. :\e:i U N o ,'o m <br /> Zoning Admi istrator ��/ 8 S 8 8 8 S v4 <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached 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 />