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Burnett County- Office of Zoning Administri for <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT 3 <br /> :W <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and '� W <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 /> reg ul��' nsof the Stateof Wisconsin. n <br /> ?.o.. �r..........q y. E C........................................ ..................................................................................... ...... % <br /> OWNER�leasa print) CONTRACTOR or SURVEYOR or AGENT <br /> ..{L':. ..A. .......v .Lr.M.,4...... .�:..... ................... . . . . . . . . ..... a <br /> . . . .. . . . ..................................................................... . m "U <br /> ADDRESS ADDRESS <br /> s�` P4uc tiro ss�� � w �- <br /> ADDRESS ADDRESS <br /> PE f+ <br /> ......�..K..... ................................................... PHONE <br /> H . . . . ...... ..LL D.....RILL-I'L....ER............................................................. ....... p� <br /> PLUMBER WE <br /> i O n <br /> ADDRESS ADDRESS n o <br /> ........................................................................................... . ........................................................................... ....... o <br /> PHONE PHO......N..E Z ,Jn r <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> 1. Work: 2. New Building Details No. Bathrooms •• •••"•' <br /> New Budding <br /> .......... Type of Constru n: No. Bedrooms .. ..... <br /> Addition ',�C/.[ tit• •••••. Septic Tank Size Gals. .. ....... <br /> Sanitary �...... Q / <br /> 1�... Size .............. ft. x .............. ft. <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... Soil Type .................. ......... ....... <br /> Mobile Home Slope .................................. ....... r <br /> .......... <br /> i <br /> Privy 3. Use (describe exactly,'1 -family Perc. Rate ........................... ....... <br /> Well .......... home,garage, motel,etc.) Dry Well .... ?� <br /> subdivisionSeepage Trench o <br /> .......... .................................................... - <br /> Camping UnitPrivy .. :✓I <br /> .......... ............................................... .... <br /> __________ Seepage Bed <br /> ________/. J.•.°i:� � .nr <br /> Location of proposed structures and existing structures well, sewage systems, roads, etc., should be sketched in Ft 1. A. FL <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 intersec ion. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. :U�Y 0 <br /> -------------_----------------------------------------------------- --- <br /> 5. <br /> _____________________________ ____ __5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq.ft. ...................................................................... ........ <br /> n <br /> N O <br /> O J <br /> J <br /> 111 0 <br /> J <br /> iT <br /> 0 <br /> O <br /> 9 <br /> N <br /> J <br /> N <br /> Cf� E <br /> M WV mrD W CO -0 <br /> m No.•< ' nm nay <br /> D p< d C <br /> ob <br /> P J J ; <br /> Z p N. O tO <br /> O D <br /> N J N a <br /> M <br /> � = m <br /> n o 0 <br /> 'D\ o <br /> A.......1....... .... .................................................... ...................................... O <br /> C_ <br /> m <br /> Signature of caner or Agent Date : $ <br /> y <br /> Remarks ............ 'P <br /> .................................................................................................................................................................................. <br /> u, <br /> 0 <br /> � O <br /> .......................................................................................................................................................... <br /> ........................ ..... m <br /> /� F �MN / .... <br /> Inspection Date ....................................... ..l.. F::IY.LLQ.!............. .....t:k.Ga.Il. ......... ..... . m <br /> J Zoning Admin�trator- L 8 8 8 8 8 8 M <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 app ication 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 bee i 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 AFPROVED. <br />