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G-yt ('XilY'Qp <br /> „urnett County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as '< — o i00 <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m 'C --':l <br /> Ordinance, Sanita n Code, and with all other applicable County Ordinances and the laws Ind regulations of the State of Wisconsin. 3 M J <br /> -c �.n.......a.�` ................................................. b...c....'l......... ........................................ N d <br /> 0 <br /> gINNER (please print) U IN or SURVEYOR or A)EN a _N <br /> g N <br /> (A�DD�R^E T p IQ ADDRESS <br /> ..................... ............................................................................................ E� i <br /> ADDRESS <br /> 1 ADDRESS <br /> PHONE................................................................................ .PHONE.......................................................................................... <br /> ........................................................................................... <br /> PLUMBER ...........D..RI.....LLE.......................................................................... :O <br /> WELL R a �/��j <br /> ........................................................................................... <br /> ADDRESS . .......................................................................................... : :� :W <br /> ADDRESS (l,s�l <br /> ........................................................................................... <br /> PHONE <br /> PHONE ............................................................................................ �z H .. <br /> J <br /> DESCRIPTION 4. Sanitary Facilities: ° o 0 <br /> 1. Work: 2. New Building Details No. Bathrooms '9 <br /> New BuildingType of Construction: No. Bedrooms .......... <br /> Addition .....,,... Septic Tank Size Gals. .._...... <br /> ... ... ................. .......................... I <br /> Sanitary .......... Size .............. ft. x .............. ft. ........... <br /> Filling/Grading Height........... Stories ............... 4a. Absorption Field Site: <br /> Moving ....4..... Area Soil Type ................... <br /> ........................................ ................. r <br /> Mobile Home .......... ... Slope <br /> ..........................................UJB <br /> Privy .......,,, 3. Use (describe exactly, 1 -family Perc. Rate ............................4...... f i <br /> Well .......... home,garage, motel, etc.) Dry Well .......... t <br /> Subdivision Seepage Trench .......... <br /> ........................4........................... <br /> Camping Unit .......... Privy u1 <br /> Seepage Bed W G <br /> -------------------------------------------------- � <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig A. Include road IL <br /> 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 0 _ a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. , 1 <br /> 0 0 <br /> 5. Lot Size: Fig, A. 6. Location: Z7 V i i <br /> ...............I ft. x .............. ft. — ............................... sq. ft. ............................................................................... I <br /> d0 <br /> N <br /> 0 0. <br /> U <br /> Y o d <br /> GS 1 70 — <br /> 0 <br /> /V J <br /> O <br /> J <br /> N � <br /> (nrv < 0 W <br /> Ip <br /> d�[ - 4 <br /> Z. <br /> Z O O D a m <br /> o <br /> y�o <br /> o�o � <br /> m <br /> .................................... 'ge"i................................. ...................................... o <br /> Signature of Owner or Agent Date <br /> X <br /> „ m <br /> Remarks ......................................................................................................................................................................... .� :��. p <br /> m <br /> ........................................................................................................................................................................................ -- <br /> ........................................................................................................ <br /> ., . ................... <br /> Inspection Date ....................................... uz./.ix�Js . . ........... ... . .�I tJ..r.,! �! !. u U o r� o m <br /> Zoning Administr t r 8 8 8 8 8 8 0 <br /> NOTE: A preliminary site inspection must be made an 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 />