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Burnett Crpuntp Office of Zoning Administri for <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT3• 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 0 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements o the n <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and <br /> regulations of the State of Wisconsin. ,.; n :p <br /> m m <br /> ...........k.BZarly..King........................................................ . . . . . . ............................................ ....... A <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT N <br /> ............ tr...A.....P OM..:.3 Q............................................... <br /> ADDRESS ADDRESS m �i <br /> A.arzkuxg.,...WZ.....5! uq..................................... ..................................................................I................. ....... <br /> ADDRESS ADDRESS i a <br /> i00 <br /> ............--........................................................................... .................................................................................... ....... (� � 7. <br /> PHONE PHONEJ� <br /> Donald Daniels <br /> ....... . <br /> PLUMBER WELL DRILLER ;-� <br /> Box W Siren, WI 54872 v <br /> ............................................................................ .................................................................................... ....... <br /> ADDRESS ADDRESS n 0 <br /> 715-349-5533 <br /> ... ................................................................................... o <br /> ....... ...... ........ ............... ...... <br /> ........... ................... ........ ..... ...... <br /> PHONE PHON......E Z N r <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> 1 <br /> 1. Work: 2. New Building Details No. Bathrooms <br /> New Building Type of Construction: No. Bedrooms . ........ <br /> Addition .......... Exist" Septic Tank Size Gals. 7 0.... <br /> ........ ......g................ < <br /> Sanitary ...X..... Size .............. ft. x .............. ft. . ........ OQ i <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Soil Type .......................s.. .. s <br /> Moving .. .... <br /> .......... ......................................... i m <br /> i <br /> o <br /> MODIIe Home .......... Slope ................................. ........ � :3, .. <br /> Privy .......... 3. Use (describe exactly,-1 -family Perc. Rate ........................ ........ o 0 i <br /> Weil ..,,,,,,,, home,garage, motel,etc.) Dry Well ..... m <br /> K : ' <br /> w i <br /> Subdivision ........ ale <br /> in ,,,f amil• ••••,•••„•.,,.,.,• Seepage Trench o u p <br /> . . g. . Y <br /> Camping Unit Privy <br /> .................................................... <br /> Z <br /> Seepage Bed o <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. ?' ELIc <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is loca ed at LP i+ <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. 7� w <br /> __________________________________ ________________________________ _ <br /> 5. Lot Size: Fig. A. 6. Location: a <br /> ................ ft. x .............. ft. — sq. ft. ...................................... E 6 '• <br /> w <br /> N o <br /> O M 3 <br /> O � <br /> � N <br /> O I <br /> - I <br /> 9 <br /> see attached plan o <br /> a <br /> J � <br /> �^ z <br /> C Z <br /> W o <br /> v <br /> io EI <br /> N I <br /> rr <br /> M in M cn r Dco co <br /> M c 1. m m O . c <br /> o -cr < ❑ O O m <br /> o <br /> 5i odcy > > 3 <br /> Z O0 •G � p <br /> O >D <br /> PND N o <br /> „ n : y <br /> o c m <br /> O <br /> c <br /> A <br /> Signature of Owner or Agent Date c <br /> y <br /> Remarks . aQ..CfJ'U'e7-” <br /> ........................................................................................................................................ ..... <br /> H <br /> .... <br /> fill <br /> � .. '7.1a�LLL ' lfNm...................Inspection Date . . .. <br /> Zoning Admini for g g $ g g N <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary f cilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this app ication 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 beE n 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 AF PROVED. <br />