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Burnett County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3• o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and d <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 and 3 i�XP <br /> regulations of the State of Wisconsin. <br /> Richard Engstrom <br /> P II N N (D <br /> 1 .4.4 ......�`..N. S7f.0!??.........................:........... c m <br /> ............ ..... ..................................—............ ?� <br /> OWNER (please prinH �OX a�7(c CONTRACTOR or SUR VOR or AGENT :o <br /> Siren WI 54872 S` C <br /> ........................................................................................... <br /> ADDRESS ADDRESS <br /> ............................................................................ :r`�., <br /> .............. ...... ...... ...... .... ADDR '•� E ` w <br /> .............. . .. .................. ESS iv1 i <br /> ADDRESS ' <br /> 715-349-5887 <br /> PHONE PHONE _ ( <br /> Donald Daniels 1S- `S '19• �d 7 E� <br /> ............................................. <br /> ...... ......................................................... WELL DRILLER '`I : i <br /> PLUMBER <br /> Box..w......Sirenx..Wl 54872............................ .......................................................................................... ° cf o <br /> ADDRESS <br /> • '•"• •• ADDRESS 0 pi <br /> 715-349-5364 ° < <br /> .................................... ........................................................................................... <br /> 0 <br /> PHONE o c <br /> PHONE ' <br /> DESCRIPTION 4. Sanitary Facilities: O <br /> No. Bathrooms 1••••••• T <br /> 1. Work: 2. New Building Details -44 <br /> No. Bedrooms 2 ••••••• i4).2 <br /> Now Building „ . Type of Con <br /> .... s rt' <br /> on: <br /> M E Septic Tank Size Gals. 1.004. — <br /> Addition ...... <br /> .......... C <br /> Sanitary ?�... Size ..sp.X ... ft. x ...J.d.... ft. <br /> bb 4a. Absorption Field Site: i <br /> Filling/Grading .......... Height......4...... Stories ....I......... <br /> Soil Type .................................... E E r E <br /> Moving Area 762p.......... .......... o <br /> Slope :......................................... N. i <br /> Mobile Home <br /> .......... <br /> Perc. Rate ...........................3...... °' , Cs E <br /> Privy 3. Use (describe exactly, 1 .family <br /> Well home,garage,motel,etc.) Dry Well Z <br /> Sin&.le family home Seepage Trench <br /> 0 <br /> Subdivision .......... ........... ........................................ o ' <br /> Privy <br /> Camping Unit .......... .................................................... Seepage Bed Mound o ? r <br /> ___ ____ ------------------------------------------------------------- (n <br /> Location of proposed structures and existing structures well sewage systems, roads, etc., should be sketched in Fig. A. W <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at 2- <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. H 0 <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS.------------ -- <br /> ------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: -� <br /> ................ ft. x .............. ft. - ............................... sq.ft. p. <br /> :i <br /> >' �N <br /> 0 <br /> y� o <br /> See State approved Plans s <br /> w <br /> T a0 <br /> :z <br /> Z <br /> O <br /> :rn <br /> :E <br /> (nv (nr > W W <br /> Na•< —' a m a a <br /> a < w C N <br /> O(A : KH OCD <br /> mm � <br /> d <br /> p y to a <br /> 'D $ n o m <br /> Z'A° ' C <br /> or-7A o <br /> ...... . .................. ...................................... <br /> Signature of Owner.or A t Date <br /> m N <br /> . D <br /> Remarks ......................................................................................................................................................................... . <br /> o . o <br /> ..................... ................;....................... ' <br /> ........................................................................................................... N N <br /> e O : <br /> p.... t. 0 N O . U <br /> Inspection Date ....................................... Zoning <br /> . A b . o N <br /> Zoning Administra o $ $ o <br /> i <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities 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 been 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 APPROVED. <br />