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Burnett County Office of Zoning Administrator �' c <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ff 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the n c ;— <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 `8 <br /> regulations of the Stateof Wisconsin. 3 c <br /> — » O <br /> ...........R.a�R.h..K..irk......................................................... . . . <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT <br /> .9.QQ9...35.xh..Ave ..N... <br /> ADDRESS d n w <br /> . ...................................... <br /> ADDRESS ADDRESS <br /> ...........NAW...iA&.Q.r...MN...5.54R.7...................................... . . . ... ................................................................................. <br /> ADDRESS ADDRESS pQ <br /> ........... ............................................................................... ..P. ................................................................................... <br /> PHONE HON......E <br /> ...........D.on..Dani.ala...................................................... ...... .. . . ....................................................................... J <br /> PLUMBER WELL DRILLER , <br /> ............................ ............................................................................................ o <br /> ADDRESS ADDRESS <br /> 0 o <br /> 7.15-34.9...5.364.................................................... ............................................................................................ N '�r <br /> PHONE PHONE Z <br /> r <br /> DESCRIPTION 4. Sanitary Facilities: o c c <br /> 1. Work: 2. New Building Details No. Bathrooms ....I.... c � <br /> New Building .......... Type of Construction: No. Bedrooms ....3.... <br /> AdditionSeptic Tank Size Gals. ..1.000 <br /> .....................I.. ....................... .. E <br /> Sanitary .....X... Size .............. ft. x .............. ft. .......... i <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Soil Type .................................... <br /> .......... ........................................... r- <br /> 0 <br /> Mobile Home Slope <br /> Privy .......... 3. Use (describe exactly,'1 -family Perc. Rate ..........3....................... <br /> Well , ,,,,,,,, home,garage, motel, etc.) Dry Well .......... T <br /> Subdivision „---,,,,, 1 family home Seepage Trencho <br /> Z :w <br /> .................................................... <br /> Camping Unit .......... Privy <br /> .................................................... Seepage Bed <br /> ---------------------------------------------------------------------- <br /> Location of proposed structures and existing structures well sewage systems, roads, etc., should be sketched in Fig. A. <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at .U,, <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. {l� „<—, <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: ;C) <br /> ................ ft. x .............. ft. — ............................... sq. ft. ............................................................................... <br /> i w <br /> INr p <br /> O <br /> J <br /> to � <br /> O <br /> 0 <br /> O <br /> SEE ATTACHED PLAN <br /> a <br /> T � <br /> Z <br /> 0 <br /> p <br /> a <br /> J <br /> m <br /> w <br /> X c m r > co C <br /> m <br /> m FL a y <br /> dD H J 3 o y `G N 0 Ip (� <br /> O d10 : 'M D <br /> xl n J <br /> C <br /> Signature of Owner or Agent Date <br /> r <br /> Remarks4/, r.-.� �I L✓f........l................... . . .................. ... .,,.................... .....r.:> M <br /> . ........................ ... / <br /> - <br /> a : <br /> ...:.....r.........................I........ <br /> Inspection Date —.>2 2 — � �......................� ...... ... .......... e . o o N m <br /> ...................1........ 9�� <br /> .......:......�. . ... ... . <br /> Zoning Administrat 15-/n 0 0 0 o o N <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 />