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Burnett County Office of Zoning Administrator cn M <br /> 0 o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT a 3 <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as N <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m <br /> Ordinance Sanitation Cotle nd with all they applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> �� ............................ <br /> a�y0 <br /> OWNER (pie s rint) ST' CONTRACTOR or SURVEYOR or AGENT a <br /> �N m <br /> ............. . .... ,.. ...................................... <br /> ADDRESS G/ ADDRESS = . <br /> .... ..w..�.^ �.........`......../OO ........... ADDRESS ` \\ <br /> ...f . . . . . . . . ........................................................................... <br /> ADDRESS <br /> ..............6/z - ./1 .-36.7. ........................... <br /> ............................................................................................ <br /> PHONE PHONE <br /> ........................................................................................... . .......................................................................................... <br /> PLUMBER WELL DRILLER <br /> O <br /> ADDRESS............................................................................ .ADDRESS............................................................................ <br /> ............ <br /> ........................................................................................... .PHONE.................................................................... Z D (— <br /> PHONE <br /> DESCRIPTION 4. Sanitary Facilities: ° 0 ° <br /> 1. Work: 2. New Building Details No. Bathrooms .......... o <br /> New Building ....... .. Type of Construction: No. Bedrooms .......... <br /> d\ <br /> Addition Septic Tank Size Gals. .......... <br /> ... .................................................... <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... t <br /> Absorption Field Site:Absorp <br /> Filling/Grading .......... Height............. Stories ............... 4a. <br /> Area ......................................... Soil Type ...................... r <br /> Moving .......... <br /> it 0 <br /> 0 <br /> Mobile Home .......... Slope .......................................... <br /> Privy .......... 3. Use (describe exactly, 1 -family Pere. Rate ................................... I <br /> XJ i <br /> Well garage,home, ora e, motel, etc.) Dry Well .......... G, <br /> Seepage Trench .......... <br /> Subdivision ...I...... .................................................... Privy .......... <br /> CampingUnit .......... .................................................... Seepage Bed <br /> ___________________________________________________________ V <br /> Location of proposed structures and existing structures well, sewage systems, roads etc., should be sketched in Fig. A. Include road A, <br /> 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- n ' <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING � [� mist <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> ---------------------------------------------------------------------- <br /> 5. Lot �e;�— a Fig. A. 6. Location: n <br /> .�... �... <br /> ft. x .IJ1... ft. . ............................... sq.ft. ............................................................................... ci- <br /> e <br /> N " O <br /> c� �ytSfino �orc�idn /,�Sf �. IN <br /> h ,U rd <br /> Ior<,ln - Oe�k ve�lacrmPnif" T � � :-�1 <br /> To be Ac ^)'e A01 <br /> L_ <br /> V <br /> n � /0'X11/' � <br /> Fm <br /> 0. Nam" d � mv <br /> ,; : — m <br /> Z oo n3M <br /> o D am 3 <br /> /� �q m <br /> I.. ..... <br /> o C <br /> iic�Zmag <br /> ture of Owner o gent Da/te <br /> Remarks ... .... � �v� /Z / �iPC- x O <br /> ...................... ........................... .............. ........................................................................ <br /> ..... .......�....... ..................................................................................................................................... <br /> V//�// m <br /> .................. . '/' \ II <br /> ................................................(((........................................................... ...................... <br /> c — N0o TfmmInspection Date ....................................... . <br /> Zoning Administrator So 8 /J <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 most 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 be made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />