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Burnett County Office of Zoning Administrator iu A o 0 <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 -< H <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use c }— <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 0. <br /> f.......... v .N..... ...... 4N . <br /> ............. <br /> a <br /> ...... <br /> OWNER (please print) CONTRACTOR or SURVEVsOfl or AGENT a <br /> {� #1 <br /> ............... .5...41............................................................... ADDR..... .S�V..c..�..l.P. ..ESSf. .}..5 `7..y..'....... y ° .J <br /> ADDRESS <br /> :E. ,T .�...�Lti..)...5.�? J'�.......... <br /> ADDRESS ............................................................................................ <br /> ADDRESS <br /> ..............> .4.`3........A; N. 8�y wSyj k� `rrI <br /> PHONE .. ....................................... . . . . .................................................................................... <br /> PHONE <br /> ........................................................................................... .W.- -1. ....D.RILLE.. R............................................................................. <br /> PLUMBER E <br /> ................................................................................. A',.......... . ..........ES.S.............................................................................. O \ <br /> ADDRESSDDRn <br /> 0 o <br /> m L7 <br /> PHONEPHONE................................................................................ :Z ?� .: <br /> DESCRIPTION ° <br /> 4. Sanitary Facilities: o <br /> 1. Work: 2. New Building Details No. Bathrooms ...Q.... � <br /> New Building .,)C•••• Type of Construction: No. Bedrooms .....<:., i o ° <br /> Addition :R <br /> .........,4,7},�,•�..�..,. o(C..., ,(�, Septic Tank Size Gals. ... .. $ <br /> ...... ... Lo i <br /> Sanitary .......... Size ......12.... ft. x ..��..... ft. ... ...... i F <br /> Filling/Grading .......... Height...l.45.... Stories ....I......... 4a. Absorption Field Site: •;" <br /> Moving <br /> .......... Area ........................................... Soil Type .................................... x iN i <br /> Mobile Home3o <br /> - <br /> ....:..... <br /> Slope .......................................... tt IF ;N,— <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... (. Q <br /> Well .,,,,.,,,, home,garage, motel, etc.) Dry Well .......... <br /> Subdivision •„......• .S"SS.�F,.� Seepage Trench .......... 4 u <br /> .......... .. �..................... <br /> Camping Unit ,,,,,••••, Privy <br /> .................................................... .......... o a <br /> Seepage Bed .......... `1 (A <br /> ---------- :L <br /> ------------------------------------------------ ----------- <br /> 01 <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc., should be sketched in Fig. A. Include road •r e <br /> setback, side and back v' <br /> yard dimension and location and setback from all bodies of water. If property is located at a highway inter- I t _a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEAR LV LABEL EXISTING q 5 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. u I':tf '^ <br /> a' <br /> --------------------------------------------- ------ O of ° <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ft. x .............. ft. — ............................... sq.ft. ............................................................................... <br /> N <br /> rt <br /> o ° <br /> o <br /> � N 5. y ACRES � <br /> X f <br /> ` I s <br /> m <br /> Z <br /> r ° <br /> a <br /> 00 <br /> �~ 37 N 0 W 2 <br /> N _. <br /> C . <br /> m m <br /> fn z m ,� ro a n <br /> 0 <br /> Z O5 : n <br /> o � <br /> rte •.lU $ � � <br /> .... . ............�.......... ......... .S l9R. m <br /> Sig ture of Owner or Agent Date y ° C <br /> RemarksX......................................................................................................................................................................... T m <br /> .............................................................................................................................................................................. <br /> Aj II <br /> ...................................................................................................... <br /> Inspection Date ....................................... ./.�- ...*":...../ i m <br /> $ m <br /> Zoning Admin strator /C j $ 8 $ 8 8 8 y <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 />