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Burnett County Office of Zoning Administratord o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. <br /> 0 <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as 'o v, <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use 1 c <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> c t — O <br /> OWNER (please print) /� CONTRACTOR or SURVEYOR or AGENT ;--V <br /> ...'..�).!�'!..e. .Is, .... ...............e:... ..u... ..... a <br /> ....................................................................................... <br /> ADDRESS ADDRESS <br /> . ..........s..................................................... . ............................................................................ <br /> ADDRESS <br /> ADDRESS <br /> ......``.a 1..: �...!..� i i� <br /> . .................................................... . .......................................................................................... : <br /> PHONEC lb <br /> ........................................................................................... ............................................................................................ <br /> PLUMBER WELL DRILLER <br /> ........................................................................................... . .. <br /> A..D.D...R..ES................................................................................. O 'O <br /> ADDRESS S <br /> o <br /> PHONE................................................................................ .PHO.....NE................. <br /> ........ <br /> ........... <br /> ......... <br /> ....... <br /> ....... <br /> .......... <br /> ................ Z o „ <br /> DESCRIPTION r <br /> 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details ° o i <br /> New Building X Type of Construction: No. Bedrooms .......... `0 <br /> m <br /> Atldition ... ...... .................................................... Septic Tank Size Gals. : '• <br /> Sanitary .......... Size .....I.9.... ft. x ....\.1,p.... ft. .......... <br /> Filling/Grading ,,,,,,.... Height.....`6..... Stories .....\.......... 4a. Absorption Field Site: <br /> Moving .......... Area Soil Type ...........................I........ I— <br /> .......... <br /> Mobile Home Slope .......................................... 1�y{1 0 <br /> .......... <br /> Priv Perc. Rate ................................... ., <br /> Privy .......... 3. Use (describe exactly, 1 -family Dry Well <br /> Well .......... home,garage, motel, etc.) <br /> Subdivision Seepage Trench .......... <br /> Camping Unit .......... �� .. Privy <br /> fXJ.:. ............. .:.... . <br /> ...... . .......... <br /> Seepage Bed .......... <br /> ______________ —fes N <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc-, should be sketched in FIB. A. Include road <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property Is located at a highway Inter- <br /> Q o <br /> section, show the intersecting highways and the setbacks required along them and at the intersection_ CLEARLY LABEL EXISTING <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. ) o' <br /> ______________________________________________________________________ <br /> 5. Lot Size: Fig. A. 6. Location: Q, <br /> 1q...ii........ ft. x ... ft. . ............................... sq. ft. ...b.e. }.....1sA. .... ... .....Y Q. ......?............... (� E <br /> D n <br /> N p <br /> A <br /> O <br /> O _ <br /> Us <br /> 0 0 <br /> s <br /> a <br /> �. '_7 <br /> 0 <br /> 0 <br /> I � <br /> co <br /> chi— <br /> g�cr <br /> IX <br /> fig Cle E- :` d n m <br /> / � ca E5 " nor <br /> 0 o0 <br /> o <br /> 0 <br /> r <br /> Q..1 c .... .r..'.................................. .'N.- ..`.�-.�..�............ <br /> Signature of Owner or Agent Date <br /> Remarks .. _ ........................................)......................................................................................................................... x i <br /> ........................................................................................................... <br /> ` ll <br /> .............................................................................................................. <br /> Inspection Date ....................................... 7CPl2CC.' jE N N H r <br /> P . . k..,......�.................... ,".,^ u u o u, r <br /> Cit ........ g g g f <br /> Zoning Admi n ist or <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilitiesf, <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached tot <br /> this application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build a <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 />