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Burnett County Office of Zoning Administrator �' c <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT 3. ;w <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and » M <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m c <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> regul 'ons of the Stat of Wi consin. ^; <br /> �'�.� .. 11 G ,...................................... ....M.�r-jh el.....K0..r..L�.r.� ...........................,.. <br /> OW lPl pant) CONT ACTOR or SURVEYOR or AGENT <br /> . .. <br /> btAt C� ...1...�....! a...�.�......................... ....... ...�C?.................................................................... d <br /> ADD ESS AD R SS <br /> .................. <br /> ADDRESS <br /> ........ ..... .��1!!..}.... ,+...... 1.1.{J...!. V/ <br /> ADDRESS <br /> : i <br /> ........... <br /> ................................................................................ . ....................................................................... <br /> PHONE PHONE......... <br /> ........................................................................................... . . ........... ....................................................................... �?+ <br /> PLUMBER WEL.. .. L DRILLE.... R : <br /> v <br /> ADDRESS ADDRESS m 0 <br /> ........................................................................................... ... .............................................. ....................................... p 11 <br /> <' <br /> PHONE PHONE.. Z H <br /> DESCRIPTION 4. SanitaryFacilities: ° g o <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details c <br /> New Bulldlno .......... Type of Construction: No. Bedrooms .......... <br /> AdditionSeptic Tank Size Gals. <br /> .......... .................................................... .......... <br /> Sanitary Size .............. ft. x .............. ft. .......... <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area Soil Type .................................... r <br /> ........................................... o <br /> Mobile Home .......... Slope .......................................... » <br /> Priv Perc. Rate ................................... <br /> m <br /> Privy .......... 3. Use (describe exactly, 1 -family <br /> Well ,. .. home,garage, motel, etc.) y <br /> Dr Well .......... � <br /> Subdivision „ , •,,,, Seepage Trench .......... o <br /> —_Camping Unit___________________ ____________________ Privy_____—__--______ <br /> . .... . ........................................ Seepage Bedi <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 located 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---------------- o 0 <br /> ____________________________________________ <br /> ] <br /> 5. Lot Size: Fig. A. 6. Location � P) <br /> ................ ft. x .............. ft. . ............................... sq. ft. . . . ................................................................. tQ' :I 1 I <br /> SL1 : <br /> 0 <br /> Yo l . I I h 6s <br /> 0 <br /> C- Z <br /> O <br /> Y <br /> m <br /> NC N W 0 a a rn <br /> n a ] ] 0 -� — m <br /> o < co353 <br /> Q U D ' <br /> N d . <br /> _ a : y <br /> o 0 <br /> � C <br /> ign- ..*'r'e" ..........-e'r- .................. ........................ ...................................... <br /> x A : m <br /> Signature of�OCwn,`�e�r or Ager��!/'� Date o : C <br /> Remark .....`�1J1.. ......:L...t.J�In .....�..... C.`.m�.. ..III�S....�1.I........l.�V .... �.. . <br /> n <br /> .................... .......).........o...........` 1 ,.,5.......Csff.)..P................................................................................. <br /> Inspection Date ....................................... . . ... . a . <br /> ....... m <br /> Zoning Administr or 0 8 8 0 $ 8 0 <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this application 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 specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />