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Burnett County Office of Zoning Administrator d o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 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 to nd Use <br /> Ordinance, <br /> Sanitation Code, and <br /> with all other applicable County Ordinancesandthe laws andregulationsof the State of Wisconsin. 3 <br /> O <br /> ..... ..4�*! '...Y. LG.4.( ...C/.Gf ................................ �G✓.G!:k�Gf^:....v.:...�.✓...`? <br /> a <br /> d <br /> O NER Iplease print) COOjN/TRAA9TOO crr SU/R'V/EVOF or AG/�E NGT a �` <br /> ........................................................................................... �!Y {7:�F4G! G'V.�........ ......................... <br /> ADDRESS ADDRESS p1 <br /> ........................................................................................... .A***D* <br /> ES..... ..'E'S"S............ ................................................................ <br /> ADDRESS <br /> .............. <br /> ...... <br /> ...... <br /> ............ <br /> ...................................................... �. <br /> PHONE. ............................................................................... PHONWELLE <br /> ... . .. . ....................................................................... Ilk,PLUMBER DRILLER <br /> ........................................................................................... .AD.....D..R..E..SS................................................................................ <br /> ADDRESS - <br /> ao Ll <br /> n O <br /> ........................................................................................... ............................................................................................ r. <br /> O <br /> PHONE PHONE z sa 'Y <br /> DESCRIPTION r <br /> 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms a <br /> 2. New Building Details o <br /> New BuildingNo. Bedrooms <br /> .......... Type of Construction: <br /> Addition .......... .................................................... Septic Tank Size Gals. .......... ! i �• <br /> Sanitary Size ft. x ft. """"" <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving ..... . <br /> Soil Type ............................ <br /> ..... ... Area ........................... ............... r- <br /> Mobile Home Slope ............................ o <br /> E <br /> .r <br /> Privy ........., 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Well home,garage, motel, etc.) Dry Well .......... I <br /> Subdivision Seepage a e Trench .......... r <br /> / .. .................................................... <br /> Camping Unit .......... Privy .......... <br /> .................................................... Seepage Bed <br /> -- --------------- cn <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc-, should be sketched in Fig. A. Include road I o' <br /> setback, side and back yard dimension and location and setback from all bodies of water_ If property is located at a hlgi wc,y inter- °- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection_ CLEARLY LABEL EXISTIKG <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. i-I o' <br /> __- -------- ----------------------------------------------------------- J <br /> 5. Lot Size: Fig. A. 6. Location: ),! <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... E i <br /> Na <br /> o J <br /> l/ 39 <br /> 0 <br /> a <br /> T <br /> z <br /> O � <br /> N <br /> J <br /> 2 <br /> V, <br /> C N T G W m N <br /> N 4 < d d m <br /> tr < <br /> E : ,� C <br /> p „ m D n m <br /> Z oo noX <br /> o <br /> W� m <br /> e? - !� <br /> ...................................... o C_ <br /> Signature of Owner or Agent Date <br /> x 70 <br /> Remarks ............................................................................... m.......................................................................................... T C <br /> I <br /> ........................................................................................................ <br /> Inspection Date1Jzr.C�./';,,,,,,j: , Ic'. I� o N o tea o N m <br /> Zoning Adm nistrator J o 0 0 0 0 o Cl) <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary faciliti(•.s <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must he attached to <br /> this application before a permit will be issued. Do not purchase or Install a septic tank, do any Flumbing or stall 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 Adm inistratoi . <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />