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Burnett County Office of Zoning Administrator d Jo 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d' <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < 7 <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use S <br /> m <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a •� <br /> 0 <br /> . . . . . . . ........................................................................ C <br /> OWNER}(please print) CONTRACTOR or SURVEYOR or AGENT m <br /> a ' <br /> 0.. -..... ...........'f ...... ......1..1..$.............................. ............................................... .................... ....................... <br /> ADDRESS / ADDRESS <br /> 1..!�......... P..P I.3.......... ............................................................................................ 0 :' <br /> ADORES ADDRESS _J <br /> ..............................................................I........................ ............................................................................................ <br /> PHONE IK/ p,pPHONE <br /> ...I."....... :5.........L� ....... .{...1.F. .................................. <br /> . ................................................................................. T` <br /> PLUMBER <br /> ..... RES.C�.F'.... ..'...t....,....U) �.s................................. . . .............................................................................. <br /> ADORES ADDRESS ( o <br /> 0 q <br /> g(Q.6..-.. Q.?.............................................. . .......................................................................................... o S <br /> PHONE PHONE Z r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms ..�. �. o <br /> New Building .......... Type of Construction: No. Bedrooms .. ... <br /> \a ? i <br /> Septic Tank Size Gals. <br /> Addition <br /> Sanitary ..... Size .............. ft. x .............. ft. ...... ... <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Soil Type .................................... �: r <br /> Moving .......... Area ......................................... •-. <br /> Mobile Home <br /> Slope <br /> Privy .......... 3. Use describe exactly, famil Perc. Rate ....3.�. ". <br /> Dry Well vNe <br /> Well etc.Aaro e, motel, <br /> `r„ <br /> ' <br /> Seepage Trench .......... <br /> Subdivision .......... .................................. h <br /> .................. Privy <br /> Camping Unit ' <br /> .......... ........ ......................................... . <br /> — Seepage Bed o <br /> ------------------------------------------ -----------------------'X_' <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road Q ' <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- a °- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> o <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. i • <br /> -------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> v M <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... i <br /> Y to <br /> N o <br /> 0 & <br /> O <br /> COL <br /> [ N <br /> m <br /> P L <br /> 0 <br /> a..: <br /> O <br /> d <br /> 7 to <br /> *^ ' 'id <br /> 7J (nr � � oyi mZ <br /> n 6o Q' a E E' f <br /> D l < <br /> rn <br /> Z O o n n X <br /> :\ en ...1 <br /> 3� ma <br /> Signature of Owner or Agent Date . . . <br /> �.. X <br /> Remarks .:....................................................................................................................... : 0 <br /> m <br /> <» <br /> ..................... — <br /> t <br /> z7r.GYz.// .. 2% .............................. ................................... ........................................ n <br /> Inspection Date ...4?..��.y`SS . �L2arcld . . . .. ............................ E_!' o o vmmi <br /> ......... ...................................... . . <br /> Zoning Admi istrator < 1 J 8 8 8 8 8 <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving 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 plumbing or start any build <br /> Ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> with is found to exist. Changes In plans or specifications shall not be made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br /> 3x/Z? 39y <br />