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Burnett County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT • .C31 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and ., C31 <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 laws and <br /> regulatio of the Stateof Wisconsin. a 1:�10 <br /> s.........(t...'F.`�!1 S..N........... ................................................................................. <br /> .... ...... r� <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT 3 � A <br /> /.� dY3yy a <br /> ......... ...................... .... ..................................................... ............................... ..................................................... ...... <br /> ADDRESS -�- ADDRESS <br /> .... ..................................................................................... ...... <br /> ADDRESS ADDRESS <br /> ........................................................................................... � rt^ <br /> PHONE PHONE �k— <br /> .... ..... n..s........................................... ..................................................................................... ...... <br /> PLUMBER WELL DRILLER <br /> O - <br /> ........................................................................................... . ....... ..................................................................... ...... _. <br /> ADDRESS ADD.. RESS...... 'm 0 <br /> o <br /> ........ON................................................................................... . ............................................................................ ...... N •• \' <br /> PHE PHON........E Z � r <br /> DESCRIPTION 4. Sanitary Facilities: o c o <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details :0 <br /> New Building No. Bedrooms �.—... :�.J <br /> c <br /> .......... Type of CoMtWctionSeptic Tank Size Gals.Addition 4X6ST ...................... <br /> - <br /> Sanitary „ .. Size .............. ft. x .............. ft. r ^ <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: V 1 <br /> Moving .......... Area ...................... Soil Type ............................ ....... i r <br /> ................... i <br /> Mobile Home Slope .................................. ....... <br /> .......... <br /> Privy .......... 3. Use (describe exactl 1 -family Perc. Rate ........................... ....... <br /> Well .......... home,garage, motel, etc. Dry Well .. ....... <br /> subdivisionSeepage Trench .. ....... <br /> .......... ................................................. .. :W <br /> Camping Unit ,,,,,,,,-, Privy .. . ... <br /> .................................................... Seepage Bed <br /> --------------------------------------------------------- <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fi . A. 1 �� <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 intersect on. <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 /> i <br /> N o <br /> J <br /> O <br /> 0 <br /> 0 <br /> f <br /> I <br /> pp a <br /> T M <br /> /} T 0 <br /> 0 <br /> O <br /> ^\, N <br /> / J <br /> m <br /> A -c 0. nccm <br /> m. Na maaM <br /> O <_ d N <br /> N m m <br /> O 1 <br /> Na :J Na ' <br /> .O <br /> o c m <br /> � 0 : 0 <br /> -�� <br /> gin <br /> . .......... ... ..... x n : o <br /> e'of ner or Agent Date : o <br /> Remarks 4:.CLZ....,F/.. ......... <br /> .............. <br /> r............ <; <br /> o <br /> o <br /> ...............................^....................................................................... ...... ..... ...... . ............... v <br /> ..-- N m N � � N m <br /> Inspection Date`-'.....L�.1........... .�...... ..... .. ... rn cn �n o o fn m <br /> .............. ..... ............................. . <br /> Zonin dministrator o $ g o o g U/ <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary far ilities 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 beer 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 AP ROVED. <br />