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Burnett County Office of Zoning Administrator Iv , N <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described ind 0 <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 nd 3 , <br /> regul ns ott¢e Sta of Wisconsin. _ m <br /> i <br /> . . . ...... . . . . <br /> ER (please print) CONTRACTOR or SURVEYOR or AGENT <br /> C........ Ax......y9.1{e. <br /> ................. . . . . . .......................................................................... ...... a ;r c,.. •-7�-p <br /> ADQRESS ADDRESS aIJ <br /> <. •ftp.�....GQu�.,..tn,�/..... ��......... ..................................................................................... ...... <br /> ADDR SS/ ADDRESS <br /> ................................. . ................................................................................... ...... <br /> PHONE PHONE <br /> ........................................................................................... . " .............................................................................. ...... <br /> PLUMBER WEELL DRILLER <br /> ........................................................................................... .......O.....RES......................................................................... ...... •O <br /> o <br /> ADDRESS AD $ 0 . <br /> _. <br /> < WWW <br /> PHONE PHONE Z <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details '•' 'o <br /> New Building No. Bedrooms <br /> .......... Type of Construction: ••• ...... E - <br /> Addition .................................................... Septic Tank Size Gals. ... ...... <br /> .......... <br /> Sanitary Size .............. ft. x ft. ..• •••••• <br /> Filling/Grading ,....,.... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ...................... . Soil Type ............................. ...... <br /> ...... .............. i r i <br /> p <br /> timeSlope ................................... ...... <br /> ✓.- Perc. Rate ............................ ...... m <br /> Privy ,.,,,,,,., 3. Use (describe -family � <br /> S'1 .......... home,garage, motel, etc.) Dry Well ... ...... i <br /> Subdivision ......•„. Seepage Trench ... ...... Z <br /> Camping Unit v <br /> .......... R..... ... ...... <br /> .............. .. � v.... ........................ Privy .;.� . <br /> Seepage Bed _' <br /> ... ..— } <br /> -- rn <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fi . A. g <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is locali id at = �� <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersect on. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. I o <br /> -------------------------------------------------------------------- -- <br /> i <br /> 5. Lot Size: Fig. A. 6. Location: E <br /> ................ ft. x .............. ft. — ...... sq.ft. ....................................................................... ....... <br /> Ptl{'P02 o <br /> ��I v be �oc�t� n `a re(51 cry <br /> f <br /> r) C 7) <br /> T <br /> Z <br /> O <br /> 9 <br /> a <br /> u <br /> m <br /> m <br /> m Nn�c am as � <br /> Z--•o .2 D � -1 <br /> o N N n <br /> n : S <br /> o c m <br /> ° : O <br /> T <br /> ........................................................................... ...................................... < O <br /> Signature of Owner or Agent Date g <br /> Remarks .................................................................................................................................................................... .... <br /> N <br /> o : g <br /> ..................................................................................................... ......... .... <br /> N Oo ;N <br /> + N$ mIns <br /> Inspection Date ....................................... .. .............. .. ... N Zoning Administrator o o <br /> NOTE: A preliminary site inspection must be made and ell granted on all structures involving sanitary fa ilities 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 beer 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 AP ROVED. <br />