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I <br /> Burnett County Office of Zoning Administrator �' c <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT W3, <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and •2 » J <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the ,tee c <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and <br /> re ug lations of the State oflisconsin. c f <br /> OWN R (please print) CONTRACTOR or SURVEYOR or AGENT <br /> . . . . ......... <br /> m <br /> ADDRESS _ ADDRESS <br /> ...... . .�... �A ..... ..i::.r..........'.............................. . ...... ................................................................................... i t <br /> I <br /> ADDRESS ADDRESS <br /> .......... <br /> ........................................................................................... .PHONE................................................................................. EJC : T. <br /> PHONE <br /> ................ <br /> ........................................................................................... ............................................................................ <br /> PLUMBER WELL DRILLER <br /> ADDRESS ADDRESS n o <br /> P..H..O...N..E.. ........... . ..... . . .. ........... N r <br /> :.......................... ...... ........... ............... .... ..P.H.O. N. E.... ................. ...................... ............ ........... <br /> DESCRIPTION 4. Sanitary Facilities: ° o °» <br /> 1. Work: No. Bathrooms T <br /> 2. New Building Details • •.....•. e <br /> New Building .......... Type of Construction: No. Bedrooms .......... <br /> AdditionSeptic Tank Size Gals. <br /> .......... ................................................ <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... <br /> Filling/Grading ......••.. Height............. Stories ............... 4a. Absorption Field Site: i ? <br /> Moving .......... Area Soil Type .................................... r <br /> Mobile Home .......... Slope .......................................... » <br /> m i <br /> Privy ,,,,,,.,,, 3. Use (describe exactly,'1 -family Perc. Rate ................................... o' <br /> Well home,garage, motel, etc.) Dry Well .......... S <br /> Subdivision Seepage Trench .......... z <br /> .................................................... <br /> Camping Unit „•,•••„, Privy .......... <br /> .................................................... <br /> Seepage Bed ......... E <br /> ---------- E <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. o. <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at `L n <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. f = <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> ______________________________________________________________________ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> -- <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... <br /> Uic <br /> 50 <br /> » <br /> Z' <br /> 0 <br /> ' o <br /> T { <br /> M \J <br /> Z � <br /> 0 <br /> p <br /> a <br /> e <br /> m <br /> m c M. N N p <br /> or o^ n 21 <br /> c: nay <br /> Zg y N 0 m m <br /> Oho D ' <br /> !: � � : m <br /> = c <br /> l~ A : : m <br /> S <br /> ..igna.... t. ...ur.. e of...Ow.....ner.. ... .or.....A..gen.. tt. - .............................. .................D.at.................... .K <br /> e <br /> Remarksn <br /> ......................................................................................................................................................................... . <br /> ........................................................................................................................................................................................ N ' <br /> U <br /> c,o 0 <br /> ................................................................................................................................. ..................................................... <br /> r <br /> ) �� f � n <br /> Inspection Date ....................................... % 6:1y2z. !... .�r......L.U..h2at ..a:2�.................... .fii7 ut vt u, o o vt m <br /> J Zoning Administrator:'f ri g g g g g g fA <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 />