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Burnett County Office of Zoning Administrator �0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m r <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. <br /> ......... I.. r.:....... <br /> m O <br /> ' .... ... <br /> OWNER (please print).......... CONTRACTOR or SURVEYOR or AGENT Y� <br /> a <br /> h1:..: 6.............. .. .. d 1� <br /> C ................................................................................. <br /> ADDRESS ADDRESS _ <br /> ............. <br /> ..S.::.a:.`...k . l � <br /> ..... <br /> ....... <br /> ...�I... . . ..... ............................................................................. <br /> t <br /> ....... <br /> ADDRESS ADDRESS T <br /> :v <br /> ........... <br /> ................................................................................ .PHONE................................................................................ ��- :v <br /> PHONE <br /> h <br /> . .......................................................................................... <br /> ........................................................................................... WELL DRILLER ``\\ <br /> PLUMBER � ° 3 <br /> ............. <br /> 1............... . .......................................................................... °O O <br /> ADDRESS ADDRESS ` <br /> P..H..O..N..E.... <br /> .......................................... o <br /> ............................................................ .......................................... <br /> .. .......... ^. <br /> - <br /> PHONE Z r— <br /> DESCRIPTION 4. Sanitary Facilities: <br /> No. Bathrooms o <br /> 1. Work: 2. New Building Details <br /> No. Bedrooms <br /> New Building .......... Type of Construction: <br /> Addition .......... ............................... I................... <br /> Septic Tank Size Gals. .......... �::,.� ,.Tf <br /> Size ..may.... ft. x ....�L:... ft. .......... i <br /> Sanitary .......... / 4a. Absorption Field Site: i <br /> FillinglGrading .......... Height..Z Stories ............... <br /> Moving Area ................................ .... ..... Soil Type ...... ......................../!.. <br /> .......... . + E <br /> Slope ................................. <br /> Mobile Home .......... <br /> Perc. Rate .......................... <br /> Privy .......... 3. Use (describe exactly, 1 -family Dry Well ' <br /> Well .•......., home,garage, motel, etc.) Seepage Trench <br /> Subdivision .......... .; .f..j.�s...l.. y <br /> Priv .......... <br /> Camping Unit .......... .................................................... Seepage Bed <br /> ------------------ cn <br /> t <br /> --------------------------------------- <br /> — <br /> Location of proposed structures and existing structures well sewage systems, roads, etc., should be sketched in Fig. A. Include road 7% a <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property Is located at a highway Inter- �. <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. b o <br /> 3 <br /> 5. Lot Size: Fig. A. 6. Location: <br /> A'..... ft. x .............. ft — ............................... sq. ft. ............................................................................... i <br /> 0 <br /> N <br /> �4 <br /> 1 T 0 O <br /> K � O O <br /> ,v J 3 s •; <br /> vl <br /> H ' <br /> c X 14' <br /> 041 <br /> cer <br /> GI216d. 2G{' T/� 9 Nr9 � ymE <br /> 1J S�s�¢MLae�w.J e� aC <br /> Z O o n rtt m <br /> Ir <br /> C <br /> .......V.Y...':. . ........ ...................... .....r.....Z........ ........... ..........�............. o C <br /> Signature f.Owner or Agent Date X <br /> M <br /> Remarks ....:.............................. .............................................._....... . <br /> .............................................................. <br /> ...............[ <.i.l.....rn ��e........ ......... ........ .........G �.....7`. ....... . . .... ..... .. .. <br /> T ....... T � <br /> rr <br /> Inspection Date ........... .......................... 1ca. NNon o <br /> , <br /> Im <br /> Zoning Ami o0 0 8 088T <br /> NOTE: A preliminary site Inspection must be made a 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 percolaUOn test must be attached to <br /> this application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or stait 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 tre made without approval Of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />