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Em,Ccstr <br /> Burnett County Office of Zoning Administrator d 1 0 0 <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 located as < H :tel <br /> H <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 <br /> with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. a � <br /> ..1..... .................................... . ............................. ........ .... ... .... . .... ............................ <br /> OWN R (pleas rint) CONTRACTOR or SURVEYOR or AGENT <br /> . .x..�..Y..7........��........3..... ...... <br /> ..C.r.o..+.x.. .a. . :... Y_DDEss <br /> ................................................... .............................. <br /> ADDRESS AESS <br /> ........................................................................................... ............................................................................................ !ill <br /> HONE PHONE r <br /> .....[ W.K.-... ....................................... . . . ..................................................................................... <br /> PLUMBER WELL DRILLER <br /> ............................................................................................ <br /> ADDRESS ADDRESS � <br /> n <br /> ........................................................................................... .P........................................................................................... <br /> Z <br /> PHONE HONE r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms <br /> .......... <br /> 0 <br /> New Building Type of Construction: <br /> No. Bedrooms .......... `�' <br /> Addition ,,,,,,,,,, Septic Tank Size Gals. .......... <br /> .................... .. . . .... .. ............. <br /> Sanitary ,,,,,,,,,, Size ! .co. ftx � �.... ft. <br /> .......... <br /> PillingtGrading Height. /? <br /> .......... Stories .....I........ <br /> 4a. Absorption Field Site: i <br /> ... .. . . m <br /> Moving .......... Area ............................... . . ..... Soil Type ..................... ...... .... . <br /> � <br /> Mobile Home .......... Slope .................... ..................... o 0 <br /> Privy 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Well .......... home,garage, m tel etc.) Dry Well .......... °1 <br /> Subdivision .......... Seepage Trench .......... <br /> Camping Unit .......... Privy .......... <br /> .................................................... <br /> Seepage Bed ......... <br /> --- ---------------------------- ------ ----------- cn <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig. A. Include road Q <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- r �- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING Q < <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> _____________________ ________________ E \.i <br /> -------------------------------- W <br /> 5. Lot Size: �d Fig. A. 6. Location: Q <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... O <br /> �o <br /> Co <br /> 0 o <br /> p e. <br /> /V �o <br /> V /3`00 X330 I —eAi6 t w T-o' <br /> t / A wel <br /> 11�' d <br /> Pit- <br /> M 0n w no y M Z Q 0 < m c c m <br /> m to < o f <br /> 'o to '< C ' m In <br /> 00 � D a m <br /> Z <br /> 0 o am 3 <br /> yr - <br /> o' <br /> ..........................`.... � o c <br /> Signature of mer or AgetDate <br /> Remarks ...Prvy.... l <br /> il ...need...asv <br /> ... ealed... ault................................................................................... m x m <br /> v <br /> .............................................. ... ................ . .... ......................................... <br /> - Nm <br /> InspectionDate ....................................... ... ....... ......... ........... ...................... : �i c rn o $ o u' m <br /> Zoning A Inistrator o $ $ $ N <br /> NOTE: A preliminary site inspection must be made and site approval granted on all Structures Involving sanitaryVy ffacll ties <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> this application before a permit will be issued. Do riot 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 />