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Burnett County Office of Zoning Administratord 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 ._. 0 <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 a <br /> .................................. � � .f'.�1 R ............................... <br /> OWNER (please print) C RACTOR or RVEYOR or AGENT m m <br /> ........................................... ............................................... a ' <br /> ADDRESS ADDRESS � <br /> ADDRESS .................................. l , &/Z.... s l .................... <br /> ADDRESS [ <br /> ' <br /> ........................................................................................... <br /> PHONE ..PHON.........E................................................................................. ( <br /> o1 <br /> .. . ...... ............................................................................... WEr <br /> PLUMBER . ....L..L.......DRI.... ..................................................................... : <br /> � <br /> LLER.... ��\ <br /> ........................................................................................... .ADD...............RESS............................................................................ O_ <br /> ADDRESS <br /> m 0 <br /> � O <br /> PHONE PHONE 0 <br /> DESCRIPTION 4. Sanitary Facilities: ° o 0 <br /> 1. Work: 2. New Building Details No. Bathrooms .......... O <br /> New Building ,,,, Type of Construction: No. Bedrooms ° <br /> .......... a <br /> Addition .......... ..............................I..................... <br /> Septic Tank Size Gals. .......... i <br /> Sanitary Size ft. x ft. .........• <br /> Filling/Grading ,,,,,..,.. Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .. Soil Type ..................... <br /> .......... ......................................... ............... r <br /> Mobile Home .......... Slope .......................................... o.. ; <br /> Privy ......... 3. Use (describe exactly, 1 -family Pere. Rate ................................... <br /> Well home, garage, motel, etc.) Dry Well .......... i <br /> SubdivisionSeepage Trench .......... <br /> .......... .................................................... <br /> Camping UnitPrivy .......... <br /> ,,,,,,,,,, <br /> .................................................... Seepage Bed i <br /> — --------------------- ------ -- cn <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig. A. Include road <br /> 0 <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. <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq. ft. .......................................................................I....... <br /> ( N o <br /> 0 <br /> Cd <br /> r <br /> d <br /> x, <br /> €r <br /> M � d ' mmZ <br /> ro aC = dam <br /> T-) <' - _ m <br /> Z o' m n a M <br /> EA <br /> o � <br /> p <br /> ............. <br /> Signature of Owner or Agent PCA-Data' o c <br /> X 3J <br /> Remarks ......................................................................................................................................................................... r : : m <br /> O <br /> ........................................................................................................................................................................................ ua <br /> W II <br /> ........................................................................................................ .. . V\ :W <br /> .. . .. ... .................... ............... ...... .. ............... <br /> Inspection Date ....................................... ... +�..L:Y. .1�V.�... ��.. �.h.... ..... .. i U a o o N m <br /> m <br /> Zoning Administr or c J o 0 o g o $ VJ <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 systerns, 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 conveyer) here- <br /> with Is found to exist. Changes in plans or specifications shall not be made without approval of the Zoning Adm inlstratol. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />