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e�Wcel 2�-f . <br /> Burnett County Office of Zoning Administrator ip <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 q Q <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and `8 <br /> regulaon ff/the Staf//Wconsin. <br /> ..��'.Ler.....:e.h.l.?:.n........................................ . . . ...................... .............................................................. tt n <br /> OWNER (please print) 11ll CONTRACTOR or RVEYOR or AGENT <br /> ............................................ ............................................................................................ <br /> ADDRESS _ ADDRESS <br /> 15 �t... P. P v { 113 <br /> ............................................... ............................ ............................................................................................ <br /> ADDR ADDRESS 1 <br /> ADD? — G.lr..�D................................................ . .......................................................................................... <br /> PHONE PHONE <br /> ........................................................................................... . . . ..................................................................................... <br /> PLUMBER WELL DRILLER <br /> o <br /> .......................................................................... . ......... .............................................................................. <br /> ADDRESS A..DDRES..S m 0 <br /> ........................................................................ .PHONE <br /> ........................................................................................... 0 <br /> ........ �. <br /> PHONE <br /> .. ........ <br /> Z � r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathroomsc <br /> .......... <br /> No. Bedrooms <br /> New euutlmg .. Ty a of Constructionn: •...•..... � <br /> { qp _. W r) Septic Tank Size Gals. J� <br /> Atltlltlon ...1^^^`.^:......................... ......... .......... <br /> .. .... .......... <br /> Sanitary .......... Size .......1.1:.. ft.x .....Z ... ft. <br /> Filling/Grading .......... Height.......... Stories .............. 4a. Absorption Field Site: <br /> Moving .......... Area ....................... Soil Type .................. <br /> .................... .................. i rMobile Home .......... Slope ........................I................. o <br /> 0 <br /> Privy .......... 3. Use (describe exactly,*1 -family <br /> Perc. Rate ................................... m i <br /> Well home,garage,motel, et Dry Well ...I...... 2 <br /> Subdivision .......... i ..��h+ Seepage Trench 0 <br /> c� F,..J...... ...�c........�............. v <br /> Priv .......... <br /> CampingUnit ,,,,,,,,,, Y <br /> ----------------------------------------.............. Seepage Bed ..........— f <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. c �� <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o, <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ..../A!D ... ft. x ....l.D.r... ft. — ............................... sq.ft. ............................................................................... <br /> O <br /> ^. <br /> N L"O <br /> o J <br /> e <br /> J <br /> 0 <br /> 0 <br /> 0 <br /> J <br /> o <br /> m <br /> 1, - <br /> � 1 Z <br /> J'i o <br /> d <br /> J <br /> b <br /> R <br /> 9 to V 0 W 0 m pl <br /> 0 �o < > > 0EE m <br /> m �a`c - am aay <br /> S< d y <br /> D 1 <br /> a = m <br /> Signature of Owner or Agent / to 'o <br /> 0 <br /> Remarks <br /> v <br /> o : c <br /> ........................................................................................................ ... .................. .. ...... . . ........................ g <br /> {//� _,�,�o; <br /> Inspection Date ....................................... ... .. . ! ' . 'XL. ................ y o rn <br /> .. .Zoning Admi i trator g g gg y <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this application 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 or 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 />