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Burnett County Office of Zoning Administrator d I o 0 <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 < — <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use c p <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 <br /> :.: .. ...:.... .............................................. ... ..:.. ............................ N <br /> O <br /> OWNER (please print) CONTRACTOR or <br /> SURVEYOR 6r AG .. . a z <br /> c r m <br /> ............................................................................ 1'11r,��a ,...GcJI S.Y.. 93 d C <br /> .......... .................... <br /> ADDRESS ADDRESS <br /> ........................................................................................... . .......................................................................................... <br /> ADDRESS ADDRESS \ <br /> .................................................. <br /> PHONE................................................................................ .PHONE.............................. <br /> ........................................................................................... ............................................................................................ <br /> PLUMBER WELL DRILLER 1 ` <br /> ........................................................................................... ............................................................................................ •0 .p <br /> O <br /> ADDRESS ADDRESS m 0 <br /> o' <br /> ........................................................................................... ... . .................................................................................... <br /> PHONE PHON.. .. E Z H <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details .......... o j <br /> New Building ,,.....,., Type of Construction: No. Bedrooms .......... a <br /> m <br /> Addition .......... .................................................... Septic Tank Size Gals. .......... <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... <br /> Fillingt Grading ......,,,• Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... Soil Type .................................... <br /> � o <br /> Mobile Home .......... Slope .......................................... <br /> Privy ,,,....... 3. Use (describe exactlyPell Rate ..................................., 1 -family - <br /> Well ,......... home,garage, motel, etc.) Dry Well .......... i <br /> Subdivision . Seepage Trench .......... <br /> .. ...... <br /> Camping Unit .......... Privy .......... - <br /> .................................................... <br /> Seepage Bed .......... <br /> __-- N <br /> Locanon of proposed structures and e osting structures, well, sewage systems, roads,etc., should be sketched in Fig- A. Includeroad <br /> setback, side and back yard dimension and location and setback from all bodies of water- If property is located at a highway inter- o- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING j <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. p' <br /> —_— _ <br /> 5. Lot Size: Fig. A. 6. Location: - - ' <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... <br /> 0 <br /> N O <br /> 3 3 jy <br /> 0 <br /> m <br /> Z \- <br /> 0 <br /> m n < m ` E <br /> N � m <br /> a <br /> 0 00 070 <br /> on - ° 3 <br /> — �' E�„ m <br /> ........................................................................ .9...../...............Y..... <br /> p <br /> Signature of Owner or Agent Date o C <br /> X <br /> Remarks ................................................................... T p <br /> O <br /> .............. T <br /> �j � r, m <br /> Inspection Date ....................................... �.1> ./...:..... ........... . .. .. .. ...... : ` o rn o v, o u, m <br /> ZoningAdr .�J 888888y <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 />