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-7 7 C- e,; o '1 <br /> Burnett County Office of Zoning Administrator o z <br /> 0 o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT rt 3 , <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as 7 O :\ <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use lvl <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 cD,f .................... .....N...S..�'.�.................. . - <br /> '� oC <br /> N G. .. ........................................................................ y <br /> OW ER (please print) CONTRACTOR or SURVEYOR or AGENT a m <br /> .............. .................... CD <br /> Q <br /> ADDRESS ADDRESS °; • <br /> ADDRESS ADDRESS <br /> ........! �. :... .s ..::...9 .. .................... ......................................................................................... <br /> PHONE PHONE \ <br /> ........................................................................................... ............................................................................................ <br /> PLUMBER WELL DRILLER <br /> 0. 'D .................................................................................... A..DDRE.........S................................................................................ _. <br /> ADD. .RESS S � C) <br /> 0 0 <br /> ........................................................................................... P.HO. H.0"NE..................................................................................... :z N• <br /> PHONE � rt <br /> DESCRIPTION r <br /> 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms T <br /> .......... o <br /> No. Bedrooms .......... <br /> New Building ,,,,,�, Type of ��structipn: <br /> Addition .......... .....,...S.1.�•fi„•L_:...................• Septic Tank Size Gals. .......... <br /> Sanitary .......... Size ....`t4.Q.... ft. x ...rf...5.. ft. .......... <br /> Filling .......... Height...4. r... Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ......7.0.0_4.......S.cT'� � Soil Type .................................... r— <br /> o <br /> Grading Slope ........... .............................. ; <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> n <br /> PrivyDry Well .......... �k <br /> ........., home,gara e, motel, etc.) <br /> Well Seepage Trench .......... <br /> ......�'. ..O.C.,.rq... ... ........... <br /> Subdivision Privy .......... <br /> .......................................I............ <br /> Seepage Bed .......... <br /> ---------------------------------------------------------------------- <br /> Location of proposed structures and existing structures,well, sewage systems, roads,etc.,should be sketched in Fig. A. Include road C ' <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- 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. r_ <br /> o' <br /> ---------------------------------- ------------ 7 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. ......................... .......................................... .. <br /> CD <br /> C <br /> //C 0 <br /> o ti <br /> LII D 0 0 <br /> z . <br /> o <br /> -� <br /> ' . <br /> 2 <br /> 1 �� � r w H co m <br /> o z o `D : fD70 <br /> o �. <br /> cn <br /> o <br /> .......... . . .. . .....: K/A o p <br /> signature of Owner ent Date <br /> X <br /> iemarks <br /> „ m <br /> ............................................ CD p <br /> CD <br /> :\ u <br /> ........................................................................................................ <br /> .0 <br /> .. ..... . ....... ....... Q : ffl-n <br /> ..................... <br /> t � oouNim <br /> nspection Date ....................................... :lZrr�Go.......:....................... J 0 0 0 . . <br /> Zoning Administrator o 0 0 0 0 o VA <br /> OTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> More construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> is application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> g until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> ith 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 />