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o(\ <br /> Burnett County f ! Office of Zoning Administrator 0 o 0 <br /> J <br /> APPLICATIOrN FOR SANITARY — LAND USE — BUILDING PERMIT d 3. Is <br /> o :J <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < N -� <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 <br /> ....... G./Ze............�"./ /.. .p.�............................... ............................................................................................ o <br /> OWNER (please print) CONTRACTOR or SUR VEV OR or AGENT m <br /> �.3 i..........S�.n. ....................................................... <br /> ............................................................................................ <br /> ADDRESS ADDRESS <br /> �jSM <br /> ..........�. ......................�,�r....... sY.dJ./.. ............................................................................................ <br /> ADDRESS :o <br /> ADDRESS ADDRESS <br /> ........................................................................................... <br /> PHONEPHONE................................................................................ <br /> PLUM BJE Rt WELL DRILLER ............................................ •p <br /> 4 / / ^'.-�6. :.!. ..!k.L.y.!..................................... . ............ . .v <br /> ......... . ................. lam" <br /> ADDRESS . ............................................................................ m Ll <br /> ADDRESS <br /> n o <br /> w <br /> PHONE PHONE <br /> r <br /> DESCRIPTION 4. Sanitary Facilities: °_ o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details •• ••••••• tN o i <br /> New Building Type of Construction: No. Bedrooms .,, .,.. iN <br /> Addition •„•, Septic Tank Size Gals. dAa4. li <br /> Sanitary ..X... Size .............. ft. x .............. ft. .......... <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area Soil Type .................................... i r <br /> Mobile Home .......... Slope .......................................... .. <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... C i <br /> Well ....-,.,,, home,garage, motel, etc.) Dry Well .......... <br /> Subdivision ,••••,,,,• Seepage Trench .......... f <br /> ................................................ <br /> Camping Unit ,,,,,-,,,, Privy .......... <br /> .................................................... i <br /> ------------------------------- Seepage Bed .......... <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 highwayinter <br /> - <br /> _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. ^^I' T. <br /> --------------------------------------_______________ 0 O <br /> _________________ ? J <br /> 5. Lot Size: Fig. A. 6. Location: r <br /> D <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... <br /> P <br /> t/1 <br /> R <br /> zlo <br /> zl <br /> / o <br /> //'! 4/r, <br /> J <br /> G / <br /> S� `P �� �I e,d , n41a -2 <br /> g <br /> : 1 J <br /> r <br /> T 1 hl <br /> Z <br /> O <br /> w <br /> J <br /> b <br /> N <br /> S <br /> Mr- 9 N ar 2 <br /> m a s < m c m <br /> _ _ f <br /> N m 'e m <br /> Z o i D n <br /> o J n 31 <br /> M <br /> M <br /> Signature of Owner or Agent0 C <br /> Date <br /> X <br /> 4x: 70 <br /> Remarks ......................................................................................................................................................................... T : m <br /> ........................................................................................................................................................................................ �hKi: <br /> v <br /> K. <br /> : <br /> Inspection Date . ... , ,. '� t ' 0 o o R m <br /> ... .. .,. 1 Ili..... .. . .......... ^ m <br /> Zonin dministrator <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, a copy of the percolation test most 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 />