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Burnett County Office of Zoning Administr itor <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 : C— <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the ,$ <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the law and 3 <br /> regulations of the Stateof Wisconsin. n q <br /> :....:f?.u. 4.��.!�.'........................................ .................................................................................... ....... F p 3 <br /> OWNER Was"' print) CONTRACTOR or SURVEYOR or AGENT o <br /> .r-X.........3:�: ..... .. .. .. .................................. . . . . . ......................................................................... ....... <br /> ADDRESS ADDRESS <br /> ....................... <br /> ADDRESS ................ ................................................................................... ........ <br /> ....... `:SIL?. iSO <br /> .. FG�..> ..................................................... ADDRESS ....... <br /> PHONE PHONE ^^\\ <br /> ` .................................................................... . <br /> .... ...... ............................................................................... ................................................................................... ........ ` <br /> PLUMBER WELL DRILLER _ <br /> O <br /> ADDRESS ADDRESS G <br /> =. c <br /> ........................................................................................... . . ......................................................................... ........ - o w <br /> PHONE PHONE...... .. Z ,3„ r <br /> DESCRIPTION 4. Sanitary Facilities: P o ° <br /> i. Work: 2. New Building Details No. Bathrooms ..... c <br /> New BuildingNo. Bedrooms <br /> �$,..�..�� Type 4L Construction: ""'•••• E � ': ;-•�{—� <br /> 44.�,,n Septic Tank Size Gals. . ........ <br /> Atltlltlon .......... ......... '.:1.!.1 ...... ........... .. < <br /> Sanitary Size ......9...... ft. x .../.6...... ft. . ........ <br /> Filling)Orading ....•.•.•• Height...9........ Stories ............... 4a. Absorption Field Site: <br /> Moving Soil Type ........................... ........ <br /> .......... Area ........................................... : o <br /> MobileHomeSlope ................................. ........ .. <br /> .......... <br /> Privy .......... 3. Use (describe exactly,-1 -family Perc. Rate .......................... ........ <br /> Well .......... home,garage, motel, etc.) Dry Well . ........ <br /> Seepagef <br /> Trench z <br /> . ........ o <br /> ............ cc11�� <br /> Camping Unit Privy ' """" <br /> Seepage Bed . . ..... Cj ,� <br /> ------------------------------------------------------------------ <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in F g. A. � Cf <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is loca led at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. N <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> --- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq. ft. ..................................................................... ......... <br /> 0 <br /> D <br /> �Sc FT <br /> 0 <br /> k�lnc�, J <br /> F <br /> _ X o c <br /> m c ium n cm cm rn <br /> o Ncr < o 0 o -. _. m <br /> m n,< - am ani <br /> v o< d c 0 <br /> r� N a ' <br /> _, <br /> o M <br /> a 0 <br /> m � C <br /> ........... `.. r.......................... %�1.. . .l .�....... x Ao <br /> Signature of Owner or Agent Date : $ <br /> T : N ' <br /> Remarks a <br /> u <br /> ........................................................................................................ .... .............. ...... —XI <br /> . . . . ......... . <br /> � m <br /> Inspection Date ....................................... ..... .. . . ............. L!l!.V.L..... . . .. .. . . .. m <br /> Zoning Administrate $ $ $ $ ca <br /> NOTE: A preliminary site inspection must be made and site appr at granted on all structures involving sanitary facilities before constr ction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this apr kcation 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 oi specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE ANDA PROVED. <br />