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Burnett County Office of Zoning Administri itor W a <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ; 3. <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 'Z + J <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements o the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 : <br /> regulations of the State of Wisconsin. _ <br /> n�-u d • <br /> ' .............................Tr MORD >n ,. <br /> ......... ....... ..... . . . ..................................................................................... ...... <br /> . ..................... . . ......... <br /> OWNER (Please print) CONTRACTOR or SURVEYOR or AGENT o <br /> 12r21 ....Qo>5....(e�9. _ <br /> ............. ... ... ............................................ .................................................................................... ....... a <br /> ADDRESS ADDRESS <br /> o 1 . , S.. f3� II <br /> ...oft.t.r..Uf- . ........K1. 5.......................o................... <br /> ADDRESS 8 ADDRESS <br /> PHONEa....`........!...1.O..................................... .PHONE........................................................................ ....... <br /> ........................................................................................... <br /> PLUMBER . ......L....D.RIL.. L......E............................................................... ....... <br /> WELR <br /> ........................................................................................... O <br /> ADDRESS . .................................................................................. ....... <br /> ADDRESS <br /> 0 o <br /> c <br /> PHONE <br /> N <br /> PHONE Z <br /> DESCRIPTION <br /> 4. Sanitary Facilities: ° o <br /> 1. Work: 10 <br /> 2. New Building Details No. Bathrooms ` I <br /> 0 <br /> New Building ....: ... Type of Construction: No. Bedrooms .. ....... <br /> Addition .....nO/, .•S}# •q..•••,.,,, Septic Tank Size Gals. ...... <br /> .... ..... ........... .. .. . <br /> Sanitary .......... Size .... `.... ft. x ...-i.�n... ft. .. ....... <br /> FillinpfGrading .......... Height....A4... Stories ............... 4a. Absorption Field Site: i <br /> Moving Soil Type .................. <br /> .......... ........................................... .......... ........ r <br /> Mobile Home Slope .................................. ...... <br /> .......... o <br /> i <br /> .. <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ........................... ....... d <br /> Well .......... home,garage,motel, etc.) Dry Well .. ....... a <br /> subdivision ,.,,,,,.,. $ Seepage Trench .. ....... z <br /> Camping Unit ,,,,,,,,, Privy .. .. .... ' <br /> • .................................................... ' ^ <br /> Seepage Bed :� <br /> Location of proposed structures and existing structures well sewage systems, roads, etc., should be sketched in Fi . A. .c <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is local d at : F <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersect on. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS.----------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. ....................................................................... ....... i <br /> (p AULS <br /> - - - <br /> -- — O <br /> f <br /> i <br /> v <br /> LV0 <br /> Y <br /> dC f <br /> J <br /> O 7 M rnvtnr Dm m '9 <br /> z � Na 000ssm <br /> r1 9 0 N : `G N 010 m <br /> O dl O D <br /> o m <br /> o 0 . O <br /> Signature of Owner or Agent Dat o : : G <br /> T: <br /> N <br /> m •• <br /> �. <br /> ......................................................................................................... ..... ........................ .... .. ,�} ....... <br /> ....... ... <br /> 0 <br /> �j//� , � N O N <br /> Inspection Date ....................................... .... . . .... ...'.......... .l,W/.41.. <br /> on Administrator $ g g o 0 <br /> NOTE: A preliminary site inspection must be made and site appro I granted on all structures involving sanitary fac lities 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 />