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C <br /> Burnett County Office of Zoning Administrator � 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3 <br /> o \ <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < � <br /> shown herein. The undersigned agrees that all work shall be done In accordance with the requirements of the Burnett County Land Use m c': <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 n <br /> a <br /> ��� ... a ................................. . .... .... .... .. .. <br /> o <br /> OWNER (please print) CONTRACTOR or SURVEYOR 6r AGENT <br /> ..... . . . ............................................................................... ...........RE.................................................................... <br /> . ............ a <br /> ADDRESS ADDSS <br /> .......... <br /> ........................................................................................... .................................................................................. <br /> ADDRESS ADDRESS <br /> . . . . .................................................................................... \lv <br /> PHONE. ............................................................................... PHONE � <br /> . .......... ............................................................................. <br /> PLUMBER W..ELL DR..ILLER O\\ <br /> .......... <br /> ........................................................................................... .................................................................................. _. <br /> ADDRESS ADDRESS n o <br /> ........................................................................................... ............................................................................................ o ,» <br /> PHONE PHONE Z u, r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> No. Bathrooms <br /> 1. Work: 2. New BuildingDetails """"" o �� <br /> New Building <br /> No. Bedrooms <br /> """"" <br /> ,,,,,,,,,, TYP i <br /> Addition .................................................... Septic Tank Size Gals. <br /> Sanitary .......... Size .............. ft. x ft. """"" <br /> Fillingl Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> SoilType .................................... i � i <br /> Moving .......... Area ........................................... o <br /> Mobile Home .......... Slope .......................................... <br /> Privy .......... 3. Use (describe exactly, 1 -family Pere. Rate ................................... <br /> Well home,garage, motel, etc.) Dry Well .......... <br /> Subdivision ✓ Seepage Trench .......... i <br /> Camping Unit .......... .................................................... Privy .......... <br /> Seepage Bed .......... i <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig. A. Include road Q <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- a - <br /> sectlon, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING < a <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — .............C..../........�...... sq.ft. ............................................................................... <br /> 0 <br /> IN <br /> a <br /> s <br /> r o <br /> Z <br /> T O <br /> 7J <br /> V � <br /> ,v7�e SSP /Yli►�w�es �ILd , <br /> % 1 tf <br /> y�8155Cdr = > � <br /> W C � ttee <br /> a _ r � N Z <br /> m c m <br /> PProuc i a a - m <br /> Han <br /> rn <br /> - Z oo a . <br /> o � aro 3 <br /> iD <br /> q m <br /> /9-�s— �- <br /> o a <br /> Signature of Owner or Agent Date <br /> X <br /> Remarks ......................................................................................................................................................................... i�..t m <br /> m <br /> ........................................................................................................................................................................................ <br /> ........................................................................................................ ....... .............. .. ....... lo. <br /> h Co w o Nu mmInspection Date ....................................... <br /> ..... <br /> Zoning Admi trator : le a a s a a a to <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 tie made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />