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Burnett County Office of Zoning Administrator c 10 __4 o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as < — 0, <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m p� <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 <br /> L — H <br /> <.. . ...TS ...�1�../.. ............................... ............................ 5 .-..../.. .......................................... <br /> OWNER (please print) //aa CONTRACTOR or SURVEYOR or AGENT o. <br /> .a... ..././l/......... 4 U — <br /> ...... .. ............... . <br /> ..................... .............................................................................. <br /> AD <br /> SS ADDRESS <br /> m , <br /> `Y�:� ..s....T.. .'c c...................................... <br /> ........................................................................................... <br /> ADDRESS ADDRESS <br /> PHONE................................................................................ .PHONE.... <br /> 00 ji Al <br /> z :41 <br /> PLUMBER WELL DRILLER <br /> ........................................................................................... . ........... ............................................................................ O <br /> ADDRESS ADD.. RESS.. m G1 <br /> ° o <br /> ........................................................................................... ............................................................................................ o <br /> PHONE PHONE Z r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms o <br /> .......... <br /> New Building ...... Type of Construction: No. Bedrooms ,✓ <br /> m <br /> Addition ,•„c••,,, ••..I.. Septic Tank Size Gals. .......... < E <br /> Sanitary .......... Size ft. x .... ., ft. ”"""" <br /> Filling/Grading „ ,,,.,,,, Height.....a....... Stories ............... 4a. Absorption Field Site: . <br /> Moving .......... Area ........................................... Soil Type .................................... r <br /> o <br /> Mobile Home Slope .......................................... O ! 0 <br /> Privy .......... 3. Use (de exactly, 1 -family Perc. Rate ................................... <br /> Well .......... home,garage motel, etc.) Dry Well <br /> Subdivision ._.,..,_„ Seepage Trench .......... <br /> Camping Unit .......... Privy .......... 'C <br /> ...........................I........................ N <br /> Seepage Bed .......... <br /> ___________ <br /> ____________________________________.___ <br /> on <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc_ should be sketched in Fig. A. Include road c � <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway Inter- as. <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> W o <br /> STRUCTURES AND PROPOSFD STRUCTURES AND ADDITIONS. <br /> I.N. —' <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ...,r.C:..... ft. x ..3.°T!.. ft. — ............................... sq.ft. ............................................................................... j <br /> n <br /> N O <br /> o <br /> 3 <br /> y O <br /> /f//V/jn�/ t•cl F <br /> Z <br /> 0 <br /> av(/ '14 <br /> to <br /> 3Od Z oo” > a <br /> F eC � p v 0 ' 3 <br /> �0 . . . � <br /> ,... /.. .. a............... .......z/ <br /> Signature of Owner or Agent ate X <br /> Remarks.,. .G.t/J/rl. .A.....r4.. 7.. ......................................................................................................... M <br /> n <br /> ....................................................................................................... ..................................... ....... :Ut <br /> . . . . . . <br /> Inspection Date ....................................... �+!IJ.2G.?..1...:.....I........ ............. o � o' m <br /> Zoning Adminls rator KJ o 0 0 0 0 o rm/1 <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary feclhtles <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 /> �3 V <br /> yzr <br /> zr6 v <br /> / s ,r <br /> � o <br />