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Burnett County Office of Zoning Administirg for <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT m 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and o <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and <br /> regulations of the State of Wisconsin. ^ <br /> ........ ....�1 ... ............................ .....................t............................................................... ...... A E?Q <br /> OWNER (please print) CONTRACTOR or SURVEYOR or, AGENT r• 1 <br /> ...... ..............�iT..�. ........................... ..................................................................................... ...... d W *— <br /> .......................... ADDRESS m '!�• <br /> ADDRESS .,. • <br /> .............P.--...7............................ . . . . . ......................................................................... ....... <br /> ADDRESS ADDRESS <br /> y� i` o <br /> ?.�..3*q. ....2 ? .......................................... . . . .............................................................................. ....... s, t,Cs <br /> PHONE PHONE <br /> h0. ................ .................................................................................. ....... <br /> PLUMBER WELL DRILLER <br /> J-.......1�/e6serr..�.r/r••�zlP� . .................................................................................. ....... o ;o <br /> ADDRESS ADDRESSC) <br /> jaP ..... Gov........................................................ . .................................................................................. ....... <br /> O <br /> PHONE PHONE Z r <br /> DESCRIPTION 4. Sanitary Facilities: <br /> 1. Work: 2. New Building Details No. Bathrooms .. .. .... <br /> New Building ✓ Type of Construction: No. Bedrooms ; <br /> .......... <br /> Addition Septic Tank Size Gals. ...Q.. <br /> .......... ............... <br /> Sanitary ✓ Size ....30.. ft. x ..... ... .... ft. . ........ <br /> Filling/Grading ••........ Height............. Stories .... ......... 4a. Absorption Field Site: ;ty� <br /> g Soil Type ........................... ........ �V o <br /> Movin .......... Area ...... . . ............. .. <br /> Mobile Home .e. ... . .. Slope .................. ,Q <br /> Privy •......... 3. Use (describe exactly, 1 -family � n <br /> Perc. Rate ........ ...... ........ m <br /> -Asor home,garage,moteDry Well <br /> l, etc.) Z <br /> n Seepage Trench . ........ <br /> Subdiv <br /> —_Camps g Unit <br /> — .......... ,.............. Privy . <br /> Camping Unit .......... .................................................... ✓.. <br /> Seepage Bed : { <br /> N 'c <br /> Location of proposed structures and existing structures well sewage systems, roads, etc., should be sketched in F g. A. <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is loca led at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the interse ion, <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> --------------------------------------------------_------------------- <br /> 5. <br /> ______________ ___5. Lot Size: Fig. A. 6. Location: l•1 ., �y <br /> ................ ft. x .............. ft. . ............................... sq.ft. ..................................................................... ......... <br /> ,tel <br /> •�' - �. + ' <br /> 0 ' i <br /> OHCS <br /> Ij <br /> f <br /> 6o ocp <br /> Z <br /> o <br /> wQ <m. n -. _. m <br /> 33 <br /> 0 !p f0 <br /> M <br /> m <br /> ......................./...:......, ...................................... ..... ...../.................. <br /> Signature of Owner of AgentDate N. o <br /> ' ; o <br /> Remarks ................................................................................................................................................................. ....... m <br /> w � <br /> ................................................................................................................................................................................ I...... rn : o <br /> P o <br /> S : o <br /> ........................................................................................................... ... .................. ..... u T <br /> Inspection Date ....................................... . ..........7. .. ........................... ....... y <br /> N - - Nm <br /> u, oou, m <br /> Zoning A inistrator <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary acilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this ap Aication 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 r 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 />