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C9/''C <br /> , <br /> Burnett County Office of Zoning Administrator Le' �c f <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3• 1 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and � 0 <br /> " 5 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 b. <br /> regulations of the State of Wisconsin. a <br /> �aT!Cn....... ...... E.... <br /> ..Avg....................... ............. ...................... <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT ; <br /> `L. K... tin...9 ...... <br /> ....lM �5.. . ............................................................................................ '( <br /> ADDRESS ADDRESS <br /> ................................................. ............................................................................................ G1 1 <br /> ADDRESS ADDRESS <br /> PP..HL..U.O..MN..EB..E.R...................... ... ...... ........... . .... ................... <br /> . ................ <br /> . <br /> ............ <br /> ............ <br /> ............. ............ ......... . O . ......... ........... ......... ........... ....... Ov t <br /> \ \M' � <br /> WELL DRILLER................................................. ....... 1 <br /> o :RI <br /> ......................................................................... ............................................................................................ _. ' <br /> ADDRESS ADDRESS 'a 0 <br /> . . . ................................................................................... ................................................... ....................................... O w <br /> PHONE PHONE Z <br /> DESCRIPTION 4. SanitaryFacilities: ) 9 S ° ` it <br /> t. Work: 2. New Building Details No. Bathrooms .......... -1 ~ <br /> Naw Building h Type of Construction: No. Bedrooms .....�.. . ;� R <br /> .......... <br /> Addition ............1"'I „ j2;,,,,,,,,, Septic Tank Size Gals. <br /> Sanitary .....>..1.. Size ft. x .... ft. <br /> FIIlinglGrading „-„ ,,,,, Height......... <br /> ......�... Stories ............... <br /> 4a. Absorption Field Site: <br /> Moving .......... Area Soil Type ...................7vk. .+.'ST.>... <br /> Mobile Home Slope ......................../.L..�f.'�.1....:.. » <br /> Privy .......... 3. Use (describe exactly, -famil Perc. Rate ......................0....... � �- <br /> Wellom ,garage,motel, etc.) Dry Well .......... �J i <br /> .......... <br /> Subdivision ,,,,,..--- Seepage Trench Z <br /> .......... <br /> . .................................................. .� <br /> Camping Unit Privy .......... : I— <br /> .......... .................................................... Seepage Bed <br /> ----------------------------------------------------------- : 1 ECP <br /> nj y RR <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. :iij <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. v`—, <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. l :p 0 <br /> --- U <br /> 5. Lot Size: Fig. A. 6. Location: <br /> 200.. ft. x ....`b L. ft. - .......2 dQ. Q.... sq.ft. ...................... 5 ...... <br /> of <br /> 0 <br /> O <br /> Eo 9 <br /> si. o <br /> AA <br /> � <br /> N m°.`< 6 N i1 EL <br /> c ,v, > > ,_ <br /> o wo ci <br /> 'Z D - --1 <br /> cit= N 4 ' <br /> o a M <br /> o c ” m <br /> o � <br /> m <br /> Signature of Owner or Agent Date <br /> 0 <br /> o : <br /> N . <br /> Remarks <br /> w <br /> o . $ <br /> ............................................................................................................ ...................... .. <br /> o : <br /> N T <br /> Inspection Date ....................................... ...... ... ...:...... . ,�-�y� <br /> - N O N <br /> Zoning dminis a or CS7Y} 8 S S <br /> NOTE: A preliminary site inspection must be made and site app vat 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 />