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d�7nr '79T <br /> Burnett County Office of Zoning Administrator iu - o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> ;w <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as < — ice. <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 n <br /> ��.Md.....11....,.. 1 �' �. .......... <br /> ' <br /> OWNER (please print) OU. VO.R o. A <br /> ENT <br /> a •� � <br /> ...1Kr..-.<r...............!/.6f....... a../C..:......................... ............................................................................................ <br /> ADDR SS ADDRESS <br /> Gl <br /> Ff .tiS.T ./.......... <br /> ...................�`✓5� .�1 .. \\�Ji <br /> ............................................................................................ <br /> ADDRESSADDRESS............................................................................. <br /> ............................................. <br /> PHONE PHONE :Z' <br /> ........................ ,yf�t/ �3ff.C�' . <br /> PLUMBER .. ............................. . . . ..... ./............................... <br /> WELL DRILLER <br /> Ci ..eC.....L .// .. <br /> _ r <br /> ADDRESS ADDRESS I <br /> n o <br /> ........................................................................................... . .................................................................................. O ..i <br /> PHONE PHONE......... Z H <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> 1. Work: 2. New Building Details No. Bathrooms <br /> .......... <br /> New Building ..... .... Type of Construction: No. Bedrooms .......... "' 0 <br /> Addition .......... .................................................... Septic Tank Size Gals. ..........may <br /> Sanitary Size ft. x ft. ... p i <br /> Filling/Grading ,,,,•,,,,, Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Soil Type ..................... <br /> .......... ........................................... <br /> Mobile HomeSlope ......................................................... <br /> C� o <br /> .......... <br /> i <br /> F. <br /> Privy ,...., 3. Use (describe exactly, 1 -family Perc. Rate .................................. .. <br /> Wel ., home,garage, motel, etc.) Dry Well <br /> Subdivision ...,,.,.,, Seepage Trench .......... i <br /> .................................................... <br /> Camping Unit .......... Privy .......... n <br /> .....................................I.............. Seepage Bed <br /> .......... <br /> ------------------- ------------- '1 i N <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road (i- 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- _a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> N P <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> ----------------------------------9__---__-------_------_—_—__--___—_— i <br /> 5. Lot Size: Fi A. 6. Location: `' <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... <br /> P <br /> N <br /> n <br /> N o <br /> O <br /> o <br /> J <br /> T �1 <br /> ,� LrJFLL. t <br /> 0 <br /> NS,. <br /> 1. <br /> r 13 :E W 2 <br /> tnam <br /> Z o 5 D n T <br /> O n <br /> ..��-..Cf.G .Cl �2< . .. �J....... <br /> Signature of Owner or Agent Date `° ' C <br /> X <br /> Remarks .................................................................................................................... � m <br /> C <br /> 61 <br /> ..................................... .................................................................................................................................................. _ <br /> S.rt: ........-.:. .... .i......i.................. <br /> ....................................................�..............9..... ....................................... assess <br /> Inspection Date ....................................... lf7rrG ....�..'.'t�..?� . <br /> T <br /> , N m , Nm <br /> Zoning Administrator 't v 0 <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 Adm inistrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />