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C," <br /> Burnett County Office of Zoning Administrator g-4g <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT 3• 3 � <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and •� M <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m c <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and ?CA _ <br /> reg la ions of the.kitate of/Wisconsin. ;: a <br /> T <br /> ..................Lr •JC.\L° . <br /> ... .......................................... ............................................................................................ <br /> OWNNA <br /> fW .. .�.......R ( lease grin CONTRACTOR or SURVEYOR or AGENT � <br /> oOd............................. .a. . .. .5.. ............ ADDRESS RESS I� <br /> n i <br /> .a.�i. �..r.. .... l .! �......... 3a........ . .......................................................................................... <br /> ADDRESS <br /> ADDRESS ;� t ;.a <br /> .......(o.S�...-��.................................................. ilY <br /> PHONE .................................. PHONE .................................................................... <br /> . .f5..........KP.e f2 ........................ <br /> PLUMBWELL DRILLER <br /> tR u...4s .r.i..w is................................. ............................................................................................ - <br /> ADORES a� ADDRESS .O <br /> � Qp� ct <br /> ... ................ ... ............................................. ............................................................................................ N <br /> PHONE PHONE Z r <br /> DESCRIPTION 4. Sanitary Facilities: ° o o ` <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details •••• • '•' `� <br /> Now BuildingT No. Bedrooms o <br /> .......... ype of Construction: •••••' -- <br /> Addition .................................................... Septic Tank Size Gals. 7,ri... <br /> Sanitary Size .............. ft. x .............. ft. .......... . <br /> Filling/Grading •....•••.• Height............. Stories ............... 4a. Absorption Field Site: <br /> .... ....... -� <br /> Moving .......... Area ........................................... Soil Type r or. <br /> Mobile Home Slope .........j� �P.................... - ih'\ <br /> Parc. Rate ...yJ�..�.. .3......... <br /> Privy .,......,. 3. earage exact) 9 -fa it o <br /> Dry Well C <br /> Well ,......... om ,garage, motel, etC. """"" ..Z <br /> Subdivision Seepage Trench .......... i <br /> .......... .................................................... <br /> Camping Unit .......... Privy <br /> .................................................... Seepage Bed <br /> ---------------------------------------------------------------- i <br /> Location of proposed structures and existing structures well sewage systems, roads, etc., should be sketched in Fig. A. ,P� •o <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at F , <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. `- <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. 0 <br /> ______________________________________________________________ Com, <br /> T1 <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq. ft. .............................................................................. ¢ i <br /> N O <br /> o � Z <br /> :�. <br /> ao <br /> � v <br /> o <br /> pe <br /> Z <br /> Z <br /> O <br /> T:W v <br /> rl- O <br /> X mvtnr Dm U1 -0 <br /> M c -. m m 0 c c <br /> m W a� a m n a W <br /> o < d <br /> C . 3 <br /> O wO 42 D 1 <br /> N= N O M <br /> o c m <br /> » 0 : 0 <br /> uv <br /> Y-, 147 <br /> o <br /> x A . : m <br /> ................................... ....................................... ...................................... > O <br /> Signature of Owner or Agent Date o <br /> Remarks . 1�'.�� Cf,A?? z:�...`- T n <br /> m .. <br /> u, <br /> .......................................................................................................... ............................................... .. ... . ................ <br /> Inspection Date � fJ r �p.�............ CL..o?.....! t(�11� .. ° ' 0 0 0 m <br /> .............. g ........... o m <br /> Zonin Admini t atoir 8 8 S 8 W <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this application before a permit will <br /> be issued. Do not purchase or install a septic tank,do any plumbing or start any building until a permit has been issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />