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Burnett County Office of Zoning Administrator &' -- Z <br /> o <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 <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 <br /> OW/ ryER (please print) CONTRACTOR or SURVEYOR or AGENT m M <br /> /••'•• • .f:...... ..... ........................................................... ../. ...W 4:,...Z<l/...1....s y ............................... <br /> AD ESS ADDRESS <br /> :.............. .:.... 4`ce'........W../..... SY..� Y............. . .......................................................................................... <br /> ADDRESS ADDRESS <br /> ........................................................................................... .PHO. NE. ................................................................................... <br /> PHONE <br /> ........................................................................................... <br /> PLUMBER .WEL....... <br /> L..D...R..ILL.....ER....................................................................... <br /> ........................................................................................... . ......... .............................................................................. O <br /> ADDRESS A..DDRES..S 0 <br /> n o <br /> PHONE PHONE <br /> DESCRIPTION 4. Sanitary Facilities: P o ,Ory <br /> 1. Work: 2. New Building Details No. BathroomsiU <br /> .. ....... <br /> o <br /> New Building .......... Type of Construction: No. Bedrooms .......... <br /> Addition .......... .................................................... Septic Tank Size Gals. .......... <br /> Sanitary Size ft. x ft. •........• '• <br /> Filling/Grading ,,,,,,,,,, Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Soil Type .................. <br /> .......... ........................................... ................... ^ r <br /> MODIIe Home Slope ................................. ........ o <br /> .......... <br /> ., <br /> j <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ...........................I....... <br /> Well .......... home,garage, motel, etc.) Dry Well .......... _o <br /> Subdivision .......... Seepage Trench .......... <br /> ................................................. <br /> Camping Unit .......... .... n <br /> ... Privy ._ <br /> ...... <br /> .................................................... h <br /> Seepage Bed .......... <br /> ______________ __ —————————————————————— Y <br /> ------__---- rn <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc.,should be sketched in Fig. A. Include road l <br /> o' <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- u La; <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING cvl <br /> 5 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> 0 0 <br /> --------- _ --------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> .......... q. ....................................................... . <br /> . ... ............... s ft. ..................... <br /> ft. x ft. — ..... <br /> ems/ '0 r' yJ <br /> O <br /> _ 7 <br /> d :O <br /> \ z i <br /> o <br /> � ra � aW <br /> fD m m <br /> < m c M <br /> -' m <br /> Z s <br /> �o m <br /> y-as-�6 <br /> ,p m <br /> ..igna................................................................... C <br /> ...................................... :W 5- <br /> Signature of Owner or Agent Date <br /> X M <br /> Remarks ......................................................................................................................................................................... :\ M <br /> m <br /> ........................................................................................................................................................................................ eq -- <br /> ... . <br /> I <br /> o � w <br /> ............. ...... <br /> a NN � m � N...... .... ....... . ............ <br /> T <br /> Inspection Date ....................................... �.... ....:.... m <br /> ............ ..... .............. . . <br /> .......................... 18 u, u, o u, o v, m <br /> Zoning Adm nistrator KJ 8 8 8 8 8 8 to <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 tie made without approval of the.Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />