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Burnett County Office of Zoning Administrator 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as <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 <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. n ;per <br /> O <br /> C�IfY..................................................... -t.(..Y.�"' `'............!..V...... ............................................ '^ <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT d :`'z0 <br /> / . ...w ...... .y93................................ a <br /> . . . . .. . . .......................... — : <br /> ADDRESS......... . .... ..... ......... .................. ... ADDRESS a .. IN <br /> m 1k\ 0 <br /> ADDRESS ADDRESS <br /> ............ <br /> . . . . ..E...................................................................... -iv <br /> PHONE. ............................................................................... PHON <br /> . . . ........I........LLER..................................................................... <br /> PLUMBER WELL DRU ' <br /> ........................................................................................... ............................................................................................ <br /> ADDRESS ADDRESS O <br /> � o <br /> ........................................................................................... ............................................................................................ o .: <br /> PHONE PHONE Z <br /> DESCRIPTION <br /> 4. Sanitary Facilities: 0° o <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details •��•�•"�� o <br /> New Building .......... Type of Construction: No. Bedrooms .......... z i <br /> Addition .......... .................................................... Septic Tank Size Gals. .......... <br /> Sanitary <br /> ....... <br /> .......... .............. . . ........ ft. <br /> Filling/Grading Height............. Stories ............... 4a. Absorption Field Site: <br /> Soil Type .................... . .. ........Moving Area ................................. ............. .... <br /> i <br /> 0 <br /> Mobile Home .......... Slope .................. ......... ............. <br /> Priv Pere. Rate .................... .............. i <br /> Privy ...... 3. Use (describe exactly, 1 -family f— <br /> WeII home,garage, motel, etc.) Dry Well .......... i <br /> Subdivision .......... Seepage Trench .......... <br /> .................................................... Priv r <br /> Camping Unit .......... y .......... <br /> v _ ; <br /> Seepage Bed .......... <br /> ---- ------------------ ------ �; 'N <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. 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 ul [h <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. 1 p' <br /> ------- ------ ---------- — --------- — <br /> — ------ �l <br /> 5. Lot Size: Fig, A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq. ft. ............................................................................... <br /> J7 <br /> �o, '� m <br /> E'N <br /> No <br /> o-13 1 0 0 <br /> y �� ipio-aL[ 9v <br /> 0 <br /> 0 <br /> 0 <br /> s <br /> a <br /> T W <br /> 0 ` <br /> d <br /> m <br /> 9 <br /> Map Z <br /> n Q < .0 c m <br /> F <br /> a k:i � m <br /> Z o o y ¢ m <br /> o a ' <br /> � `o <br /> C) <br /> ign <br /> .......at.......ure...of....O..wner.........or....Ageen <br /> t t...' .............................. .................D. ......... <br /> ...... <br /> ... o C <br /> Sat.. e <br /> X 70 <br /> Remarks ......................................................................................................................................................................... m m <br /> O <br /> v ' <br /> ...................................................................................................... . ...... ..........J................ <br /> .N .N . a. ._ H.N <br /> mInspection Date ....................................... ........... M nO <br /> oningAm�tOrrZd. .. .... <br /> 8 8 0 8 8 8 y <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, it 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 />