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(11I I4 <br /> Burnett County Office of Zoning Administrator Cc, <br /> --I0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3. <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < <br /> C <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use A <br /> Ordinance, Sanitation Code-�;�all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> ... V..� ... . ....1 "r i2sa�y ...........................................................................I................ ice\ <br /> s O <br /> OWNERa e p <br /> ( erint CONTRACTOR or SURVEYOR or AGENT o. <br /> ..............1.. .......(.�� . EL".....6z.. ...... ............................................................................................ <br /> ADDRESADDRESS <br /> /IJ <br /> ....... � .......... •.•. .. .ADDRESS........................................................... <br /> ADDRESS ................. <br /> i <br /> ............................. ......... ry <br /> ........... ........... <br /> . ... . <br /> . <br /> . <br /> . <br /> . <br /> . <br /> . <br /> . <br /> . <br /> . <br /> .......................................................................................... <br /> iU.. . ...... ............ ............` . ................................................. . . . . .. . . . . . . .................................................................... <br /> PLUMBER 7 WELL DRILLER <br /> UIl - <br /> ......... . ........ ; <br /> 0 <br /> ADDRESS ADDRESSn o <br /> .................................................. <br /> ...:....................................................................................... . ........................................ <br /> a' <br /> PHONE PHONE Z r <br /> DESCRIPTION 4. Sanitary Facilities: ° 0 <br /> No. Bathrooms ....�..... (a <br /> 1. Work: 2. New Building Details o <br /> New Building ...6;�we Type of Construction: No. Bedrooms ......�... '� <br /> Addition •,.... ,,,,,,,,,, .••,,, f.•,,,,,,,, Septic Tank Size Gals. .......... <br /> .. . .....L............. .... <br /> Sanitary .......... Size ...�T . ... ft. x ... ft. .......... <br /> Filling)Grading $ 4a. Absorption Field Site: ' <br /> .......... Height... ........ Stories ............... <br /> . <br /> ......... <br /> Type ......................... . <br /> Moving .......... Area ..................... ..................... Soil <br /> Mobile Home <br /> Slope .......................................... .-- .. <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Dry Well <br /> Well home,garage, motel, etc.) """"'. <br /> Subdivision Seepage Trench .......... 1 <br /> .......... '•�ia�•�,ii•wi. ••gkJQibii.�... Privy .......... j :(.i� <br /> Camping Unit .......... ................ ... r- <br /> .......... <br /> VJ f 1* f�f�l7 fi ri•1� Seepage Bed ......... <br /> ___ t ___ <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig. A. Include road '1 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- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> ------------------------- <br /> 5. <br /> _____________________5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — sq.ft. <br /> ............................... ............................................................................... <br /> 1 m <br /> N o' <br /> 20 ✓+D o <br /> E � <br /> 71 <br /> t• <br /> Z- <br /> ( o <br /> m u m M : j M Z <br /> •'{� � fA a n� _ —' n <br /> �Hm D n IT <br /> Z03 n 7] <br /> O o n m 3 <br /> J GJrS <br /> UN LMkrL I V� m <br /> ...... ..r. ...,.�.............. .... ..Wl ..� .............. o C <br /> Signa ure of wner or ge� Date X 70 <br /> ........ ...............................:.............................................................................................. <br /> m <br /> Remarks ........:....................... <br /> ............... ..... ...... ro� ..... '.... ... .. .e.................................................................. <br /> ill <br /> ....................................................................................................... ✓[/,f Trr <br /> .......... ....Inspection Date ....................................... U <br /> Zoning Admniator <br /> NOTE: A preliminary site inspection must be made 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 />