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'—eJ9C. e9 — <br /> Burnett County Office of Zoning Administrator V 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. 3 <br /> ° :G <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 1 c <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 n ;O <br /> 7 s...........z ��°.4 .............................. . .......................................................................................... <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT <br /> a <br /> 01. .. ...........f!. ^....:... .....w./...y........... ............................................................................................ <br /> ADDRESS ADDRESS ,°i. <br /> ........................................................................................... .ADD.... R.......ES................................................................................ � <br /> ADDRESS S <br /> fir <br /> PH....................................................................................... .PHDNE................................................................................ :h <br /> ...R. ... r� .r.................................... ........ <br /> ..................................................... <br /> PLUMBE <br /> WELL DRILLER <br /> A <br /> ........................................................................................... 'A"616 <br /> ADDRESS............................................................................ <br /> ADDRESS � CCC <br /> C) <br /> PHONE PHONE H <br /> kl <br /> DESCRIPTION4. Sanitary Facilities: n° 0 0 <br /> 1. Work: No. Bathrooms is M <br /> 2. New Building Details <br /> New Building yp T e of C str No. Bedrooms i <br /> � R e: <br /> Addition ,,,_ ,,,,, }-Q,,,, /S r /n ,,, .. Septic Tank a Gals. F <br /> V <^ <br /> Sanitary ... ... Size .............. ft. x .............. ft. sf'X!r /n 7..5...0, 11S . <br /> R: <br /> Rillingr Grading .......... Height............. Stories ............... 4a. Absorption Fiel ite: <br /> 14: <br /> Moving .......... Area .....................................I..... Soil Type .................................... >;: iCI) r i <br /> Mobile Home .......... Slope .......................................... t? eC <br /> o <br /> Privy Perc. Rate ................................... <br /> .......... 3. Use (describe exactly, 1 -family <br /> Well Dry Well <br /> home,garage, motel, etc.) •••• •• u <br /> Subdivision .......... � <br /> g SeeP a e Trench .......... i <br /> Camping Unit .................................................... <br /> .......... Privyi <br /> .................................................... <br /> .... ... O. <br /> Seepage Bed J,&''V§3 — y. <br /> --------------------------------'----- .N 'lr <br /> Location of proposed structures and existing structures,well,sewage systems, roads etc., should be sketched in Fig A. Include road o C <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- o. a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> o' y------------------------------- r C <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ft. x .............. ft. — ............................... sq. ft. ............................................................................... <br /> 0 <br /> N O <br /> O J <br /> J <br /> 0 <br /> 7 <br /> ^� S <br /> ttV, D <br /> m <br /> 0 T <br /> O <br /> R u <br /> J <br /> r✓ m <br /> < >Z <br /> fM <br /> p C M <br /> ` y ry <br /> vfa ii ' m � . E <br /> 'O OI < m O c m <br /> z o0m <br /> ' 0 Da <br /> m <br /> W � <br /> ?v o m <br /> . ............... <br /> rr d\ m <br /> Signature o caGner Agent Date <br /> Remarks � x . . . <br /> /l .��v-P� „ m <br /> ................... ................................................................................................................................................. <br /> ........................ ... .. ..........,........................................ ........................................................... <br /> ......................... .. . ... . .. ..... ...........:. . ................. II . . . : <br /> . ....... ............. <br /> Inspection Date .......//).... J/�;/ m <br /> ^/�. .K... ... .fKIFkP .../....t .................................... O N <br /> Zoning Admin' trator �I/ 8 8 8 8 8 8 of <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 be made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />