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Burnett County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT d 3• 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and '2 p i_S <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the ,$ c <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> regulatio s of the State of WiscAQsin. <br /> Am�h.111J ............... .M..S.M5.. ...!'.95-?0 f.re.�!.. ..! ��1�� F <br /> OWN R Iptease print) CONTRACTOR or SURVEYOR or AG/EtN <br /> IS 1 .....I........ X...... �'7'. ............................... <br /> ..........33.11.......�3.....f .Y....... ................................. ........ . . ... <br /> ADDRESS ADDRESS m <br /> M. .pt..t5......... !-ir11.........59-4c................. ..........SpOniuk-R............. .SG?1....,..... <br /> ADDRESS ADDRESS <br /> ..........�La.......:.7.t�...sail................................... ......... .. C /'�� .. . . <br /> PHONE PHON .L�.J.......�EJ�J .... Qv-7........................�.. <br /> ........................................................................................... WEL. . . ...... .RILLE.. R. . .................................................................�..... <br /> PLUMBER L D <br /> ........................................................................................... ............S-'.............--........ ................--..... <br /> - .......................... .................. —..... <br /> ADDRESS ADDRESS W i <br /> ° <br /> », <br /> ? <br /> . . . ................................................................................... . ................................................................................... � <br /> PHONE PHON........E Z r <br /> DESCRIPTION 4. Sanitary Facilities. �O o ° <br /> 1. Work: 2. New Building Details No. Bathrooms ...aZ... <br /> New Building .,, '... T`ype of Construction: No. Bedrooms .IY.... E: - <br /> ..LQ... ra ... Q4tUwC0 <br /> Addition .......... G... P....lS........................... O <br /> Sanitary .......... Size ..4.X...... ft. x ...�.8.... ft. Septic Tank Size Gals. 7.5] ./� <br /> Filling/Grading .......... Height............. Stories ............ 4a. Absorption Field Site: <br /> Moving .......... Ar¢e Soil Type .................................... o <br /> ........................................... Slope ................................... . <br /> Mobile Home .......... ""' v <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ............................:...... <br /> Well .......... home,garage,motel, etc.) Dry Well mSeepage Trench .......... o <br /> Subdivision .......... ....L.....FAt-U.tiy..... e>.!€........... <br /> Camping Unit ......... Privy •$).i <br /> . .................................................... Seepage Bed -L <br /> ---------------------------------------------------------------------- <br /> Location of proposed structures and existing structures well sewage systems, roads, etc., should be sketched in Fig. A. v <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at .¢` > S a <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. �.Cj:O S' •„„ <br /> —————————————————————————————————————————————————————————————————————— <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — sq. ft. .� E i <br /> N <br /> 0 <br /> 0 <br /> 0 <br /> T 'VJ <br /> Z <br /> O <br /> J <br /> b <br /> N <br /> \. <br /> :.0 <br /> M CP -0U) r- D W W <br /> Z�o � 1 <br /> o ND <br /> 0 LT <br /> /3' x m <br /> Owner or � .... ....... ....6.-......... ........... ° <br /> Signature of Owner or Agent Date o <br /> Remarks .......Ail ......erU.Jr.4s/.CA.4.k.'...../.l(1..C1...a <br /> N v <br /> .............. .... .... J/ . ........ .......:.... <br /> Inspectibn Date TL/)���'�/�'I� N N N +On <br /> . . . •....................................... .. ..: . ..� ..... ........Zoning AdminatraNOTE: A preliminary site inspection must be made and site approv'� granted on all structures involving sanitary facilities before constructs <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 />