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Burnett County Office of Zoning AdministratorM 0 1" o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. <br /> 0 <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 e <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 i v <br /> G�>. C �.. ......... a...s3.��.e�¢i!n-!.......................... N <br /> O <br /> ........................................ <br /> OWN R (please print) CON�R CTO or•SURVEYOR or AGENT v. <br /> ./r;../......................................... .Ol. ..... �C ... G6G.L:.?p.............................• ........ v <br /> _ <br /> A .ESS y ADDRESS <br /> 2- ' <br /> ... .....7.a��.,.w/.........:SS'Rv..... ................ <br /> ADDRESS ADDRESS ' <br /> ........... <br /> ........................................................................................... ..........E....................................................................... <br /> PHONE PHON <br /> ........................................................................................... ............................................................................. <br /> WED ............... \ <br /> PLUMBER WELL DRILLER <br /> .......... <br /> ........................................................................................... .................................................................................. <br /> ADDRESS ADDRESS n o <br /> n < <br /> ...... <br /> ............ o <br /> . ... . ............ ..........E...................................................................... Z <br /> PHONE PHON <br /> r <br /> DESCRIPTION 4. Sanitary Facilities: n ° o ° <br /> ° <br /> 1. Work: 2. New Building Details No. Bathrooms '�'��•"•� � o � <br /> New Building .......... Type of Construction: No. Bedrooms ..........F 0 <br /> Addition ... ............••............ Septic Tank Size Gals. .......... <br /> Sanitary .......... Size .............. ft. x ft. """"" fi <br /> Absorption Field Site:Absorp <br /> Filling/Grading .......... Height............. Stories ............... 4a. W <br /> uilType .................................... r <br /> Moving .......... Area ........................................... Sor o <br /> Mobile Home .......... Slope .......................................... Vt ,+ <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... w <br /> Well .......... home,garage, motel, etc.) Dry Well .......... w <br /> subdivision Seepage Trench .......... o <br /> Camping Unit .......... .................................................... Privy .......... <br /> Seepage Bed <br /> ----------------------------------- t i <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc-, should be sketched in Fig. A. Include road 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- <br /> section, show the Intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> 0 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. v o <br /> --------------------------------------------------------------------- i <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ftp. . /./.......`.........././.�............ s9. ft. ............................................................................... <br /> J� 0 o <br /> 1 f I = <br /> rs n <br /> v 1 <br /> o <br /> l <br /> d <br /> 0 <br /> I � <br /> �o <br /> Y n <br /> s <br /> - m <br /> Z <br /> 0 o n � 9 <br /> _ m 3 <br /> :9J o 70 <br /> / J _ <br /> ........................................................................... ...................................... o C <br /> Signature of Owner or,Agent Date <br /> X <br /> Remarks ......................................................................................................................................................................... m m <br /> m <br /> v <br /> is <br /> .................... ................................................................................ .. ........... . �/ . . p� . . . . . T <br /> Inspection Date �r���JlL SL/ \C u "' "' "H' m <br /> ....................................... ................ t° rnrnornornm <br /> Zoning Ad Inistrato `� <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 />