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I <br /> Burnett County Office of Zoning Administrator g-4g <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT m 3. 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and0 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the ,� r� <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and d <br /> regulationspf_the State of Wisggnsin. CL <br /> 3 _ <br /> ri <br /> Co <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT <br /> 8 4 I N .. ia. rh ................................................................................... ...... a <br /> ... .......... ........................... ...�. :... :................�......1.... _ <br /> ADDRESS l - �„•tvv ADDRESS O1 <br /> ADDDDRESS ... ... . ................................................................................... ...... <br /> ADDRESS , <br /> ........................................................................................... ..................................................................................... ...... <br /> PHONE II 66�� PHONE `` <br /> PLUMBER.A. "..V..{ .. ..G":. WELL DRILLER...................................... ......................................... ........../....l ................ ...... O i <br /> ii y "Q i <br /> ........................................................................................... 1 O <br /> ADDRESS . ......................................... <br /> ADDRESS ..�...........�� > ......... ...... ° �C) <br /> F <br /> {t" <br /> ° <br /> c <br /> . . . ................................................................................... .PHONE................................................................................... ...... D, : , <br /> PHONE <br /> DESCRIPTION 4. Sanitary Facilities: o �r <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details ••• ••••• <br /> ° <br /> Now Building . x. Type of Constrytion: No. Bedrooms �•• <br /> ��• $ <br /> Addition ........... •!f`.Y.)..(,.y.+^.................. .. Septic Tank Size Gals. ... .. ... <br /> Sanitary .. ... Size ...1..`f...... ft. x ....4'....1.x. ft. -7•a••• <br /> FulingfGradinq ,,,,,,,,,. Height............. Stories ............... 4a. Absorption Field Site: ; <br /> Moving ......... Area Soil Type ............................. ...... r <br /> Mobile Home .......... Slope ................................... ...... � <br /> o ? <br /> Privy Perc. Rate ............................ ...... <br /> .......... 3. Use (describe exactly, -family � <br /> Well .. .•..... home,garage, motel,etc.) Dry Well ... ...... �1.i <br /> Subdivision .,, ,,.,,, Seepage Trench Z` <br /> .................................................... ... ...... °\J <br /> Camping Unit .......... Privy < <br /> .................................................... Seepage Bed //-- <br /> __ y i(A <br /> f <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig A. N� T L <br /> Include road setback,side and backyard dimension and location and setback from all bodies of water. If property is local d at or <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersects n. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o' <br /> ________________________________ J <br /> ____ __ l <br /> 5. Lot Size: Fig. A. 6. Location: E ? Z <br /> ................ ft. x .............. ft. . ............................... sq.ft. <br /> iN <br /> Y. <br /> T <br /> o <br /> �Y S [ <br /> �._. ._._.... "o, o E c. <br /> aoa . a u 3 <br /> o'wo � D -i <br /> cn= Na ' <br /> o a Im <br /> � � o m <br /> a » <br /> _ 0 <br /> c� .•..... ...................................... m <br /> ............ .... ...)...y....................�........................ : A <br /> Signature of Owner or Agent Date / o <br /> Remarks '1 � . ....V.f......-.y1.U—....... nul�........"`I"........ // . ........... .. .................... i./.'........ .. a_ <br /> T <br /> r. 1 (R... ...... ........ — .. <br /> .:.... .................... ........... .......... ... ....................... ... .... <br /> Inspection Date ... ...-.7................/............ . . . . a <br /> Zoning•Administrat��r1j . . $ $ g 41 <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary fats sties before consiructio <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 ssued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or s ecifications 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 />