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Burnett County Office of Zoning Administrator 3 I'o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT Z I;4. � <br /> ' 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < H -* <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use - c <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 0- <br /> e r...........!) n 4 ail S <br /> ................ ..... ............. ............................. ............................................................................................ N (D <br /> OWNER ( ase print) CONTRACTOR or SURVEYOR or AGENT m <br /> ........... <br /> ....R.�........J............. ..�/ .S .4. .1.!�.................... Q <br /> .............................................................. <br /> ADDRESS ADDRESS °+ r <br /> ............. �n <br /> 4DDRESS ADDRESS <br /> . ........................................................................................ P..H.. ...ONE.. .................................................................................. <br /> 'HONE <br /> . ........................................................................................ . .......................................................................................... <br /> 'LUMBER WELL DRILLER <br /> ................................................................................ J\ <br /> ....................................... �• C <br /> 4DDRESS ADDRESS <br /> 0 <br /> ............................................... P H........ONE................................................................................. z <br /> 'HONE <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° S' <br /> 1. Work: 2. New Building Details No. Bathrooms o <br /> New Building Type of Construction: No. Bedrooms .......... 0 <br /> Addition Septic Tank Size Gals. .......... <br /> Sanitary .......... Size .............. ft. x .............. ft. <br /> Filling „•_ Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Area Soil Type .................................... r.......................................... <br /> o <br /> Grading X... Slope .......................................... <br /> Mobile Home Perc. Rate ................................... <br /> .......... 3. Use (describe exactly, 1 -family <br /> Privy .........• home,garage, motel, etc.) Dry Well .......... <br /> Well „••„•••• Seepage Trench .......... 1/U <br /> Subdivision .................................................... Privy <br /> .......... .............I...................................... <br /> Seepage Bed <br /> -------------------------------------------------------------------- <br /> _ocation of proposed structures and existing structures well,sewage systems, roads etc., should be sketched in Fig. A. Include road <br /> ;etback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- a "1 <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. <br /> _ O� <br /> ---------------- ------------------ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... <br /> :C <br /> n n <br /> r+ <br /> o <br /> r-r <br /> 0 <br /> z <br /> o <br /> CD <br /> C w` <br /> cu c m z C c co <br /> d <br /> OH: C ' G co m <br /> �. <br /> 0 <br /> ry n _ ^� m <br /> .................... .......... ........�.3..... :moo p <br /> gnaiure f Own or Agent Date h <br /> X 70 <br /> marks m <br /> CD <br /> CD <br /> ..................................................................................................................................................................................... <br /> V) <br /> ......................................................................................................... .............f ........... ............................... C' o o cNi, m <br /> spection Date ....................................... g. ... ............ �... C`j o o 0 0 o rrt <br /> Zonin Administrator !0 o o o o fA <br /> )TE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> ore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> s application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> h 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 />