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Burnett County Office of Zoning Administrator 3 CD 0 0 <br /> s APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. _ <br /> o � <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 CD m <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> y <br /> .a. /13.CY!!4..C...... -..... ..�'t.l.C. S.P..?�?........... ....U...`� . . ....Q. .-.4V1.. . ..�!3.s.............. C CD <br /> OWNER (please print) CONTACTOR or SURVEYOR or AGENT CD <br /> CL <br /> ...M 3....cA. ...s7E...&,�..................... ............. / - r <br /> a <br /> ADDRESS ADDRESS CD <br /> N�..U.�?. ......1��....5 y�3d.................... <br /> AD[7RESS ADD ESS <br /> �. � ...4. 5. .. 3 ...?5:-................................ o .fit <br /> PH E/2 .../... 1..'.... ..Y.70................................... PHONE <br /> PLUMBER WELL DRILLER <br /> ........... <br /> ADDRESS ADDRESS 0 o <br /> ....................................................................... .......................................................................................... _r <br /> PHONE PHONE Z o .a <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° ` <br /> 1. Work: 2. New Building Details No. Bathrooms n o N <br /> No. Bedrooms .......... � L <br /> New Building .......... Type of Construction: CD <br /> Addition Septic Tank Size Gals. .......... h <br /> .. ...........................I........................ <br /> Sanitary Size .............. ft. x .............. ft. <br /> 4a. Absorption Field Site: <br /> Filling .......... Height............. Stories ............... <br /> Moving Soil Type .................................... _ <br /> Area ........................................... �. o <br /> GradingSlope .......................................... �v <br /> Mobile Home .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... y� J <br /> Dry Well <br /> Privy .......... home,gar ge motel, etc.) """"" N ; <br /> Seepage Trench .......... R <br /> Well .......... .... ................... Privy <br /> — Subdivision """ "' >�.......... ........ ........................................... <br /> Seepage Bed ......... :.� <br /> ------------------------------------------------------------ z <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc., should be sketched in Fig. A. Include road s <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- o <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. 0 > <br /> ------------------------- G - ———————————————————————————————————————— <br /> 5. Lot Size: Fig. A. 6. Location: ,y <br /> cJ :c Z <br /> ................ ft. x .............. ft. — ..7....... ..........5..... sq.ft. ............................................................................... <br /> Cn <br /> M h <br /> o <br /> � p <br /> o :z <br /> N <br /> rf <br /> • w <br /> .Q o <br /> l <br /> • T\ 7 <br /> -n <br /> CD <br /> 0 <br /> UD <br /> CD <br /> ��- <br /> cnr _ cncoZ <br /> C: CD c CD <br /> rj <br /> o �. � � � m <br /> Z 0 O CD fD M <br /> o f 5 : . R <br /> n <br /> 0 <br /> `4 0 <br /> 0 <br /> m <br /> CD <br /> : C: <br /> Signatu of Owner or Agent Date — <br /> .ar� lY U�e .....�- G „ " o <br /> �/,//� //�//� Q ,(� <br /> Remarks .. ..:...... ...... .............G�............. .%....r!)......... FCC:............... <br /> 111 K..... ................................. CD <br /> i <br /> CD <br /> /�. �. :.... ................................................................................................................................ <br /> ....... .................................................................................................. ... ............�Zoning <br /> ...... ............................. i, <br /> ' NT <br /> Inspection Date ....................................... . ..................................... o 0 0 0 0 o m <br /> A inistrator o 0 0 0 o cn <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 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 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 Adm inistrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />