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Burnett County Office of Zoning Administrator c <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 nd .. <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of he ,8 <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws nd 3i-7 <br /> regulationsof the Statteof Wisconsin. <br /> Q.— • <br /> .......................... .................................................................. ..... n �/ <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT <br /> ....RE...i...... ox......43.0.3........................... ...................................................................................... ..... d 7c <br /> ADDRESS ADDRESS 1 <br /> V2.�.'45N5 ..€.&...W.0.................... ...... ............................................................................................ <br /> ADDRESS ADDRESS <br /> // Q ^J ADDRESS ; {,f <br /> ............1/..Q. 4... .�� C .(r ............................... ............................................................................................ <br /> PHONE PHONE .` <br /> ........................................................................................... ............................................................................................ <br /> PLUMBER WELL DRILLER <br /> 0 1 \ , <br /> ........................................................................................... . ......... ....................................................................... ...... <br /> ADDRESS A" C)S 'm 0 <br /> 0 o <br /> ........................................................................................... ...................................................Y................................ ...... ,`.• <br /> PHONE PHONE Z r, r — <br /> DESCRIPTION 4. Sanitary Facilities: P o <br /> 1. Work: No. Bathrooms ... <br /> 2. New Building Details ••• ��� � c <br /> New Building „( .. Type of s uction No. Bedrooms ... ...... <br /> Addition .., ,.q',I ,•,••'„�•,s„� Septic Tank Size Gals. ... <br /> Sanitary Size .....�.,. ft. x .... ..F..'.:rrt. ... ...... SJ <br /> Filling/Grading Hei ht. �...... Stories ............... 4a. Absorption Field Site: <br /> .......... 9 .f• <br /> Moving .......... Area Soil Type ............................. ...... E <br /> ........................................... o <br /> Mobile Home Slope ................................... ...... •. <br /> .......... <br /> Privy ....•.•••. 3. Use (describe exactly,"1 -family Perc. Rate ............................ ...... <br /> Well .......... home,garae,motel, etc.) Dry Well ... ...... <br /> Subdivision �y�- , �„ Seepage Trench o <br /> Camping Unit .......... ............ Privy .. .... (`; <br /> .................................................... Seepage Bed <br /> ... ..— <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. F <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at L <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersect on. � ` N <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> ___________________________________________________________________ _ ' <br /> J <br /> 5. Lot Size: ��� Fig. A. 6. Lon�io ::// A <br /> ................ ffx .............. ft. — ............................... sq.ft. .....1.%f.. e�'(T .................................... . Q i i <br /> Wt <br /> ° <br /> o <br /> 0 <br /> ` t a <br /> m <br /> N <br /> Z <br /> ° <br /> M <br /> d <br /> 7-NO 65F, <br /> M .N -otor D W W <br /> / m Nii� � nN nny <br /> I-Au <br /> �2 � <br /> �Q� D =t <br /> CCT o c m <br /> QQ a » = O <br /> ..... ... . ......... . ..... .......... ......... <br /> C <br /> m <br /> m <br /> nature of Owner or Agent Date o O <br /> o ; <br /> N <br /> T . <br /> m •• <br /> ................................................................................................................................................................................... . <br /> o : <br /> ..................................................................................................... <br /> Inspection Date ....................................... .."..". .........Z..o..n..i.n...g Administrator <br /> Lt <br /> ra..tor <br /> NOTE: A preliminary site inspection must be made and site app"?g"no �llh••'•a uNg, Ovg, ugN, og <br /> Nv, <br /> structures involving sanitary faJyyyJJilitias before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this apptI ation 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 issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or pecifications 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 />