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tf-n <br /> Burnett County Office of Zoning Administrator i? F c <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 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 ?-1 <br /> regulations of the State of Wisconsin. <br /> CL <br /> J.EA. �............... I/??. �/d. '5o '............. . .......................................................................................... <br /> OWNER (pleaa/se print I CONTRACTOR or SURVEYOR or AGENT <br /> Q.4� .. NS.`�.. ............................................................................... a <br /> .. . ....... ... .N........... ... .�.. .......................... - <br /> A . RESS ADDRESS . ); 9 <br /> .0. ..7 . . ........ o . .........m. ........ ............................................................................................ <br /> ADDRESS ADDRESS0 � <br /> ................y . �.-.r...a. ...z. .................................. , <br /> PHONE PHONE <br /> ........................................................................................... .............R'"I'L ......................................................................... _. <br /> PLUMBER WELL DRILLER ;..j <br /> ........................................................................................... . . .. .................................................................................. .o - <br /> ADDRESS AD.. ..DR..ESS m 0 <br /> o <br /> < 'r <br /> ........................................................................................... . . .................................................................................. O <br /> PHONE PHONE...... .. Z ,n„ r• D <br /> DESCRIPTION 4. Sanitary Facilities: ° o o :r- <br /> 1 <br /> r <br /> 1. Work: No. Bathrooms .......... 7 <br /> 2. New Building Details <br /> New Building .... .... Type f Cc`nstru�ctQi n: No. Bedrooms .......... ! <br /> Addition _ ,,,,,,�••, (";;<wY ,;:; -, Septic Tank Size Gals. .......... <br /> Sanitary .... .......... <br /> y Size .....,. . ft. x ..I L ...... ft. i <br /> Filling/Grading „ ,,,,,,,, Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... AreeSoil Type .................................... r i <br /> ........................................... <br /> Mobile Home Slope <br /> o <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... _ <br /> Well ....... home arage, otel, etc.) y <br /> Dr Well .......... � <br /> subdivision �.L� Seepage Trench z <br /> .......... .......... 0 <br /> ......... ......�.- .:..._..................... <br /> Camping Unit .......... Privy .......... <br /> .................................................... y� t <br /> Seepage Bed .......... � <br /> ----- -------------------- ---_ ____ <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. c <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at ',j <br /> FL <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> I i <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... r <br /> IN Ei <br /> q `l <br /> r� o <br /> Z <br /> 0 <br /> N c N r n cm cm -V <br /> or cr o – – m <br /> m Nn < am naA <br /> m H > > 3 <br /> N <br /> C D ' <br /> MU <br /> o p <br /> > O <br /> Signature of Owner or Agent Date <br /> o , <br /> Remarks ” m <br /> m •• <br /> .......................................................................................................�.�......................� .. ...................... .............. o <br /> !1 0 <br /> Inspection Date ....................................... .... /17Rh'1� .. .. ..... 'lt'� �.�..r�................. N �n N o m <br /> .... . . ..... ........ y,( <br /> Zoning Admini rator-�/�) - 8 $ go rn <br /> i <br /> NOTE: A preliminary site inspection must be made and site dpproval 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 />