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Burnett County ' Office of Zoning Administrator D I 3=1 1 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ; <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as .6- <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m o) iQ <br /> Ordinance, Sanitation Code, and with all other applicable County �O_r/di�inaancees.,and.the laws and regulations <br /> �of�the State of Wisctlread. 3 a <br /> ... '.............. .... ....................................... �..<..(.'^' !''�": .`r . V."�"�.1-{! o................IL...... 'N^ <br /> » ? <br /> OWNER (please print) 7 CONTRACTOR or SURVEYOR or AGENT a <br /> m <br /> ............................................. .ADD.. ... ...R... ......................................................................i......' a •� <br /> ADDRESS ESS.. <br /> ADD....R. .ES.......................................................................IL...... <br /> ADDRESS S <br /> PHONE ................................................... PHONE <br /> ........................................ ....... . . . .............................................................�....... <br /> PLUMBER WEL..L DRILLE. .R �� <br /> o <br /> ADDRESS ADDRESSm 0 <br /> ........................................................................................... PHONE. . . . .......................................... ........................ .... ....... o <br /> O <br /> ... <br /> PHONE f z N <br /> DESCRIPTION 4. SanitarvFacilities: <br /> 1. Work: No. Bathrooms ..�....... of <br /> 2. New Building Details o <br /> New Building ........ . Type of Construction: No. Bedrooms .......... y 0 u <br /> Addition .......... .................................................... Septic Tank Size Gals. .......... I; i <br /> n: <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... A: <br /> Filling)Grading .......... Height............. Stories ............... 4a. Absorption Field Site: lit: <br /> Moving .......... Area ........................................... Soil Type ............................ ....... <br /> N' o <br /> Mobile Home .......... Slope .......................................... . + <br /> Priv Perc.Rate ................................... C E <br /> Y .......... 3. Use (describe exactly, 1 -family IJ <br /> Well home,garage, motel, etc.) Dry Well ..... <br /> Subdivision ..✓.,. Seepage Trench .......... <br /> Camping Unit Privy.......... .......... <br /> .................................................... <br /> Seepage Bed .......... <br /> ----------------------------------------- — ----- ------ <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Includ road o e <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- O a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXIS ING y <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> 0 <br /> ------------------------------------------------------------ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... s9. ft. ......................................................................I`........ ? '. <br /> 0 <br /> N O <br /> O O <br /> 0 <br /> s <br /> I O <br /> 'A .� <br /> z <br /> o <br /> d <br /> I �1 <br /> � mz <br /> 0 <br /> n <br /> o � m nm <br /> Z o o <br /> o � nm 3 <br /> o ° <br /> W 9 <br /> ....................................... °l_ c <br /> Signature of Owner or Agent Date <br /> X <br /> :A11 Remarks ...................................................................................................................................................................l..... � m <br /> .................................................................................................... .. ..... :::.::::::: :::::: :::.J::::: ; <br /> II <br /> U . .o . .o . <br /> . U <br /> mInspection Date ....................................... .: I,ZoningAd r K✓ <br /> 888888rmn <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures in olving 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 plu bing or start any build- <br /> ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the inf rmation conveyed here <br /> with is found to exist. Changes in plans or specifications shall not be made without approval of thte Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br /> — J <br />