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Burnett County Office of Zoning Administrators �/ 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < H o <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 i V <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 M V <br /> S cmc _ <br /> ... Q�/26,>.ao.................................... ................................... — <br /> OW07ER (please print) CONTRACTOR or SURVEYOR or AGENT a <br /> a m <br /> ax sb(C.......... .l.V.r •..'�'y!:4,:.. 1......�S, y y ............................. a <br /> ... <br /> ADDRESS ADDRESS <br /> �/tl i ttiy <br /> 51P93 <br /> ...................... .......................................................................... E <br /> •`O <br /> ADDRESS ADDRESS <br /> ........................................................................................... ............................................................................................ <br /> PHONE. ............................................................................... PHONE <br /> . . . ... . . . . ...................................................................... <br /> PLUMBER WELL DRILLER <br /> ADDRESS............................................................................ .ADDRESS............................................................................ io <br /> K -� <br /> o <br /> -. 0 <br /> ........................................................................................... ............................................................................................ o » <br /> PHONE PHONE Zr <br /> DESCRIPTION 4. Sanitary Facilities: f,-° o <br /> 1. Work: 2. New Building Details No. Bathrooms 3 o <br /> New Building No. Bedrooms .......... -0 <br /> .......... Type of Construction: <br /> Addition ......•••• ..............................•, Septic Tank Size Gals. .......... 1, i <br /> Sanitary Size ft. x ft. <br /> .......... .............. ..... ........ a: <br /> FillinglGrading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving ..... Soil Type ................. <br /> ..... ........................................... ................... oi <br /> Mobile Home Slope <br /> Priv Perc. Rate ................................... w <br /> Privy .......... 3. Use (describe exactly, 1 -family � <br /> Well ., home,garage, motel, etc.) Dry Well ........,. <br /> ........ <br /> Subdivision ✓ Seepage Trench i <br /> .......... .................................................... <br /> Camping Unit ......•... Privy o ' <br /> .................................................... Seepage Bed <br /> ---------------------------------------------------------------------- <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc., should be sketched in Fig. A. Include road <br /> setback, side and back yard dimension and location and setback from all bodies of water. Ifg - <br /> propertY is located at a hi hway inter- u1 a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING C <br /> P <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. � p' <br /> _—_ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... i <br /> o <br /> 0 <br /> r <br /> 0 <br /> � F <br /> Nia <br /> Z <br /> o <br /> A <br /> a <br /> w <br /> 61 <br /> i61 <br /> 77N r v N to Z <br /> m <br /> N N d n c N d m <br /> yam <br /> Z O o <br /> o <br /> \carr <br /> / \•sl o = � � <br /> Signature of Owner or AgentDate <br /> �o C <br /> X <br /> Remarks ......................................................................................................................................................................... 't, �.! m <br /> m <br /> ..................................................................................................... .... .............. ..... ...................,........................... Lt '�C <br /> T <br /> /J�__/ w /•� / N; N N m + N m <br /> Inspection Date ....................................... .. cfu.r�.......... ................ .... .................... al u. U 'o v, o v. <br /> Zoning Admin K✓ fmn <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 />