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et'County Office of Zoning Administr for <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work describe and '� # 0 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements o the ,$ c <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the law and 3 � <br /> regulations of the State of Wisconsin. 3 , <br /> ,Pabaf 6eifruo'G SchrO f s <br /> ......... ............................... .................. ....................... ....... <br /> OWNER IPleese Printl ' "' ' .... <br /> ........... <br /> .•'. ....... <br /> C �1h i�� CONTRACT R or SURVEYOR or AGENT o <br /> f` .. ...........t.................................................................. ... <br /> ADDRESS .................................................................................... ....... m <br /> .ninon ADDRESS <br /> ........:.. .....4�... n ....ss9�7 <br /> ADDRSS .. .. ............................... ... ................................................................................ ....... <br /> ADDRESS <br /> PHONE o?J...............-.a. ..5.�... .l.o.................................. . .................................................................................. o <br /> ....... <br /> PHONE <br /> i <br /> LUM13 .............. � <br /> m.............................. <br /> PPLUMBER . . ................................................................................ ....... <br /> WELL DRILLER <br /> .............................................................� i; k,(I' Sl . ...................................................A ................. ....... 'O <br /> ADDRESS <br /> P� �y... <br /> ... .............................................................. .............................................................� �......... <br /> HON ........... ....... c <br /> PHONE <br /> DESCRIPTION 4. Sanitary Facilities: ° c o <br /> 1. Work: N <br /> 2. New Building Details o. Bathrooms <br /> New Building <br /> .......... T . Bedrooms <br /> ype Cotruction: <br /> ✓ .. .... g <br /> of C <br /> Addition )� Septic Tank Size Gals. <br /> Sanitary ,. Size ...P..C.I/!.. ft. x ...... ... ... ft. ... ...... � <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... Soil Type ............................. ...... r <br /> MODiIa Home .......... Slope ................................... ...... .O. <br /> v <br /> Privy 3. Use (describe exactly,'I -family Perc. Rate ............................ ...... <br /> Dry ° <br /> .......... home,garage,motel, etc.) Dr Well .,, .-,,,, m i <br /> subdivision /Q /•. Seepage Trench ... ...... Z - <br /> .......... x . r-yf.......................... o r\, <br /> Camping Unit .......... ........ Privy ..... <br /> -- ............................................ Seepage Bed .. ...... <br /> Location of proposed structures and existing structures well sewage systems, roads, etc. should be sketched in Fig. A. <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is local d at <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. <br /> __ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> o <br /> ft. x .............. ft. . ............................... sq. ft. ............... 1 � <br /> See <br /> LJ <br /> # 16416 <br /> T 1t� <br /> Z <br /> O <br /> p <br /> n <br /> J <br /> N <br /> M (n v (Ar Dor m -0 <br /> m_v Nac - am an S <br /> c: 0 <br /> S o 3 <br /> o'wo <br /> En n <br /> , a : 9 <br /> 1�................ .................. <br /> In <br /> 3D....................... /011,17A _ <br /> Signature of Owne or Agent Datea In <br /> Po O <br /> o : <br /> Remarks <br /> T: N <br /> m •• <br /> ...................................................................................................................................................................................... . w <br /> o : o <br /> 0 <br /> ........................................................................................................... <br /> ... ................... <br /> ....... <br /> . ..q. ... <br /> ... ...... <br /> Inspection Date ....................................... o ' m <br /> .... . .................. ./ u... o in <br /> Zoning Administrat 8 0 8 8 0 8 m <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facil ties before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this applici tion 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 sp cifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPR)VED. <br />