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Burnett County Office of Zoning Administrator iu 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT � 3 <br /> ° \ <br /> located as '� — 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and <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. 3 a V <br /> G,z .��,.a.�z....... c.,... f.l.��. <br /> N <br /> rt,.................... <br /> . <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT m _ 0 <br /> 1�.: .. ....Q1�....1. . .............................................. ............................................................................................ d € <br /> ADDR SS ADDRESS <br /> l t1.0St�.fb..... ....... :y.k.9....3........... <br /> ADDRESS ADDRESS................................... :$Z <br /> . .f <br /> .............................................. <br /> PHONE .. ............................................................................................ Y\ <br /> .. . ...... ............................................................................... PHONE <br /> PLUMBER . .......................................................................................... <br /> WELL DRILLER <br /> ........................................................................................... <br /> ADDRESS . .A...D..RES.. .... S.............................................................................. <br /> Do <br /> PHONE PHONE................................................................:............... ? <br /> < <br /> DESCRIPTION 4. Sanitary Facilities: P o 0 <br /> 1. Work: 2. New Building Details No. Bathrooms '9 <br /> New Building •,•••• T No. Bedrooms .......... ^'• z ' <br /> Addition Type of Construction: <br /> ., . .... . . . Septic Tank Size Gals. .......... '• <br /> Sanitary .......... Size IoZ........ ft. x .-2..... ft. - •••••• i <br /> Filling/Grading ......•... Height........... Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... Soil Type .................................... m <br /> Mobilo Home o <br /> ......... Slope .......................................... ; <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Well home irage motel, etc.l Dry Well .......... ,� i <br /> Subdivision ' •�� lea L�er� Seepage Trench <br /> W <br /> y <br /> Camping Unit ......•••. Priv .......... ry <br /> .................................................... f <br /> Seepage Bed ..... <br /> ----------- — -- — — <br /> -------- ---- ---- ---------- -- _ ..... I .`1 <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,shouldbe sketched in Fig. A. Include road <br /> cFIN <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- a <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. <br /> -------------------------------------------------- <br /> J :f. <br /> 5. It Size: Fig. A. 6. Location: r�. <br /> ..7..3..4... ft. X/.- ft.ft. — ..�.`L. ..0.0.......... sq.ft. ............................................................................... <br /> IA\1f P <br /> IV <br /> •Y <br /> � J <br /> J_ <br /> ] :Af <br /> O <br /> W boa FP <br /> • 1 m :� <br /> Z <br /> 0 <br /> r1 � <br /> eo -6 to < C R <br /> m . <br /> Z �� [ aS70 <br /> t • <br /> Signature of Owner or Agent // Date <br /> Remarks..5:v. .. a!?..ta la.7 X m <br /> v <br /> ..................................................................................... <br /> . .. .............. .....Q........ <br /> .......... . <br /> . ................ i...................................................................................................... II <br /> mInspection Date ....................................... ator �j g g gZoning Amn <br /> g g g y <br /> TOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> efore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> his application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build <br /> Ig until a permit has been issued. A permit may be revoked if misrepresentation of any ,f the information conveyed here <br /> lith is found to exist. Changes in plans or specifications shall not be made without approval of the Zoning Administrato, . <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />