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Burnett County Office of Zoning Administrator c 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3 <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < h :h <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m e <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a W <br /> 1 ��� N m O <br /> ......1`1......... �,JI ................................. .... 1.. .................................................................... C = ctCp+ <br /> OWNE WI please print) p COCTOR or SURVEYOR or AGENT a t7 <br /> .X... �..��....C.�........................................................ ............................................................................................ <br /> ADDRESS <br /> ADDRESS <br /> ?R.N...Rio. .........4Isc.........59�3�......... ............................................................................................ <br /> ADDRESS / / �jC/ ADDRESS <br /> PHONE ............................................ PHONE X <br /> ............................................... ............................................................................................ ' <br /> PLUMBER WELL DRILLER <br /> O <br /> ADORESS............................................................................ .ADDRESS............................................................................ A O........................................................................................... ............................................................................................ �z <br /> PHONE PHONE <br /> DESCRIPTION 4. Sanitary Facilities: / ° o ° <br /> 1. Work: No. Bathrooms AJC°�' <br /> 2. New Building Details "' . o <br /> New BuildingNo. Bedrooms /`Jew'Et <br /> •........ Type of Construction: • <br /> Addition .•••• 0 0 U Septic Tank Size Gals. <br /> .. .. .W.... ................... <br /> Sanitary •••••..... Size /," ft x Q�^r� f <br /> r... .iti..�.... t. .......... 3: <br /> FillinglGrading g Nt 4a. Absorption Field Site: <br /> .......... Hei ht.�........ Stories ...0.......... ? : <br /> SoilType .................................... r i <br /> Moving .......... Area ........................................... Sop <br /> Mobile Home .......... <br /> Slope .......................................... .. <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ............................. ..... <br /> Well .......... home,garage, motel, etc.) Dry Well <br /> Subdivision ,/t/ - - Seepage Trench <br /> .......... ..�(�l�/ -e..�..L.. ./ `.....,.�.. y .......... <br /> Camping Unit O1+e.Q Priv . ........ t <br /> _________________________________ Seepage Bed________— W .N : <br /> Location of proposed structures and existing structures,well, sewage systems, roads,etc., should be sketched in Fig. A. Include road Q <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter <br /> section, show the Intersecting highways and the setbacks required along them and at the Intersection. CLEARLY LABEL EXISTING O a <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. N o -� <br /> ____________________________________________________________________ <br /> 5. LSize: Ap Fig. A. 6. Location: / �r 01 M <br /> .7/.�......... ft. x .. .7u... ft — ...............�............ sq.ft. .. ..... ......F� ............ o <br /> ........................ / <br /> A <br /> a o U <br /> I e <br /> I _ 1 4- 73 <br /> s <br /> ZZ <br /> Cv r 3 O <br /> JJ <br /> N r SGA <br /> a <br /> a <br /> 0 <br /> m <br /> ° 3 <br /> � N � a <br /> 3, <br /> 0 <br /> ...r �, m <br /> .................. .../- ..�r ...... <br /> Signatu of Iva <br /> or Agyent Date X <br /> Re rks ✓C. a..�li. ....•.41..... ,� : : . 0 <br /> ..... ................................................................................................................ . . : <br /> ...................................................................................................... .. ................... <br /> b: <br /> a <br /> T <br /> Inspection Date ....................................... .�rYl.1< .. ............. .... .�....................... u, v, o u, o N m <br /> Zoning Adm at, K 8 8 8 8 8 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 />