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Burnett County Office of Zoning Administrator 0 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT <br /> 3 0 <br /> m o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as '< N <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m m >\ <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a � <br /> a O <br /> w � <br /> OWNER (Please Print)- ..-..--.............-*........ ....... CONTRACTOR or SURVEYOR or AG ENT............�................... a <br /> ............... .... .. ........ ......................... .ADDRESS............................................................................ <br /> ADDRESS <br /> s.. Af......Rfi..a..... . ..). 5 .`. ..................... ..... . ................................................................................... <br /> ADDR SS ADDRESS :PJ <br /> ..................2 5`183 0 � <br /> .................................. ... . .................................................................................. o <br /> PHONE PHONE.... .. <br /> ......... ..15........S...E6......X�19............................... ............................................................................................ <br /> PLUMBER WELL DRILLER \, <br /> ........................................................................................... . ......................................................................................... <br /> ADDRESS AD.. DRESS <br /> � o <br /> 0 <br /> o < <br /> . . . ............. o <br /> PHO ...................................... .............. P.HO. N. .E. ........................... ................ ............... ...... .: <br /> DESCRIPTION 4. Sanitary Facilities: a ° o ° <br /> 1. Work: 2. New Building Details Poi , Cote( No. Bathrooms v ' <br /> .......... n <br /> �/ ,t <br /> New Building ,/,\,,, ype of onstruction: stfuc lu lP No. Bedrooms .......... ONM <br /> Addition „ -(;eQYj Oy Q0?„ ,,,,,,,,,, Septic Tank Size Gals. .......... .1 <br /> ...-... 1} < <br /> Sanitary .......... Size .�yC..... ft. x ....a: ... ft. .......... <br /> FillinglGrading ,,........ Height............. Stories ............... 4a. Absorption Field Site: i <br /> N <br /> Movin9 .......... Area .....................I..................... <br /> Soil Type .................................... <br /> Slope .......................................... o <br /> Mobile Home <br /> .......... 4 i 0 i <br /> Privy ,,..... 3. Use (describe exactly, 1 -family Perc. Rate .................................. <br /> WellDry Well .......... <br /> home,garage, motel, etc.) <br /> Subdivision Seepage e Trench C. <br /> .......... ' <br /> Camping Unit .......... Privy N <br /> .......... <br /> .................................................... Seepage Bed <br /> .......... <br /> ---------------------------------------------------------------------- <br /> Location of proposed structures and existing structures,well, sewage systems, roads,etc., should be sketched in Fig. A. Include road d <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. p <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location1 <br /> .... ft. x .660. ft. — ............................... sq. ft. <br /> S..a............................................_ . Xce��tic <br /> E��s'� �LC� Feed I Seg I� Twp r-/0 <br /> o <br /> �o <br /> o �1 <br /> 0 <br /> T : \ <br /> u �A\ Na+ Less <br /> tier Ion Pee <br /> N TGfeenhouSe U <br /> o I <br /> 0 <br /> c m M :k mIZ <br /> Y � <br /> m Nn < dnw <br /> /< minm <br /> alp 3in — <br /> � C, <br /> 000 ''Ej Rd C oto z <br /> . ...........�� ............ . .................. ...................................... ; o C <br /> Sin re of Owner or ent Date <br /> X M <br /> Remarksl.UP... /1d!.:�cRiGJr....:S,I.F.��1.7....................................................................................................................... E 0 <br /> .................................................................................................. ...... <br /> )c..................../...... ......... ...... .................................. ' T <br /> Inspection Date ....................................... gJry /- � e! . >d i �' u u 'o o ren m <br /> ...................... en <br /> Zoning Admfhistrator /C 8 8 8 8 8 8 f/7 <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 />