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Burnett County Office of Zoning Administrator o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as o <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use la c <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 t0a <br /> (please ..�:......�J....�.r�..�...<.T.� �. . . . . '65 �..�...�...�.............................................. F <br /> OWNER (please print) NTRACTOR or SURVEYOR or AGENT m <br /> a <br /> 3........ .� ..I. 'D..�� �N ....11161 <br /> .. . <br /> S ........................................................................................... d <br /> � ES`S 1 ADDRESS .. y <br /> ................................................................. ............................................................................................ <br /> ADDRESS .� ADDRESS <br /> i <br /> .%.5....-.. ..�' .:-...�-.x...7.1...................... ................ <br /> PNE .PHONE ...................................................................... � <br /> ........................................................................................... . . . ..................................................................................... ?� <br /> PLUMBER WELLDRI LLER .� <br /> ........................................................................................... . . ..................................................................... <br /> ................. <br /> O <br /> ADDRESS ADD.. .. RESS <br /> n o <br /> PHONE ........................ PHONE o <br /> DESCRIPTION 4. Sanitary Facilities: r o 0 <br /> 1. Work: 2. New Building Details No. Bathrooms o I <br /> New Building XNo. Bedrooms .......... 0 <br /> .......... Type of Construction: <br /> Addition • ........ .............. .^ ,,,,,,, „-,••,,,,,•„ Septic Tank Size Gals. .......... <br /> ............ H <br /> Sanitary .......... Size ...../..d.:... ft. x .... . .... ft. ; <br /> Filling/Grading g i / 4a. Absorption Field Site: <br /> .......... Height Stories ...y.�........ <br /> ......../../....... .:. . ,y.:. ......... Soil Type .................................... r <br /> Moving ,,,,-,,,,, Area <br /> Mobile Home .......... Slope ............................ ............. W <br /> ............. <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ...................... t <br /> Dry Well .� <br /> Well ,.,,,,,.., home,garage, motel, etc.) _ � �������� : <br /> Subdivision ....... .. .. ....(..-. ?. .�../>�....... .d U.lJ�- Seepage Trench .......... '� <br /> Camping Unit .......... Privy .......... <br /> .....................I.............................. r <br /> ------------- Seepage Bed ......— <br /> --__ ————————————————————————— O . <br /> In <br /> Location of proposed structures and existing structures,well, sewage systems, roads, etc.,should be sketched in Fig. A. Include road W <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. j 0, <br /> ---------------------------------------------------------------------- e <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. r: ....//.../.CY.k�Lll/7.......: .62.. ............... <br /> Co <br /> n <br /> N O <br /> o <br /> 3 <br /> ry 0 <br /> y\\ O <br /> V h <br /> 0 <br /> a <br /> v <br /> M Nr W to <br /> -"4on <br /> C m lP <br /> Z <br /> :�j <br /> m <br /> Signature of Owner or Agent f Date x <br /> 000 <br /> Remarks .............................................................. ......................................................................................................... p <br /> v <br /> .......................................................................................................... .... . ............................................... i <br /> /� % N N tll N m <br /> Inspection Date ....................................... ....7:?2L.a....�...... . . . . .. ................... m <br /> Zoning Adminis ator F'J 8 8 8 8 5 8 V1 <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 Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />