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Burnett County Office of Zoning Administratord z <br /> 0 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 '< 0 V <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. c <br /> 3 C <br /> . •!+: •: ..: !liCLch�............................................ ...�,.......f.OWNER (please print) ;?r4 f'?i................................... <br /> ) ACTOR <br /> or SURVEYOR or AGENT o. m <br /> ............................................................................ 5.��: .. J . a � <br /> ADDRESS ..................... . ................................... <br /> ADDRESS _ <br /> CC�EG <br /> A...D..D...R..E..S.S.. . . ........................ ......... <br /> .... % 6 F_ f` <br /> ..-................................... <br /> ............... ........................ ........... ............ J .. <br /> ADD <br /> m <br /> � <br /> ........................................................................................... . ..............................................................................RESS <br /> ............ <br /> PHONE PHONE <br /> cvt <br /> ........................................................................................... . .......................................................................................... <br /> PLUMBER WELL DRILLER <br /> ........................................................................................... <br /> ADDRESS . ........................................................................... ...... <br /> ......... <br /> ADDRESS �� C) <br /> o <br /> PHONE <br /> DESCRIPTION4. Sanitary Facilities: ° o <br /> 1. Work: 2. New Building Details No. Bathrooms v <br /> O <br /> New Building .......... Type of Construction: No. Bedrooms .......... V <br /> Addition .......... .................................................... Septic Tank Size Gals. .......... i <br /> Sanitary Size ft. x ft. •......... <br /> RiliingfGradin9 .......... Height............. Stories ............... 4a. Absorption Field Site: i <br /> Moving .......... Area Soil Type .................................... <br /> ....................................I...... r <br /> Mobile Home Slope .............................. ........... <br /> o <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Well home,garage, motel, etc.) Dry Well .......... i <br /> Subdivision 1/ Seepage Trench .......... <br /> .......... .................................................... <br /> Camping Unit ,,,,,,,.,, Privy ,,,,,,,,,, <br /> .................................................... Seepage Bed <br /> ---------------------------------------------------------------------- <br /> Go <br /> Location of proposed structures and existing structures well, sewage systems, roads etc., should be sketched in Fig A. Include road 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 5 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> 0 <br /> ---------------------------------------------------------------------- i <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft.. . ............................... sq. ft. ............................................................................... <br /> rn <br /> e3 N <br /> p7 <br /> — o <br /> - -R <br /> m <br /> J — 0 <br /> 0 <br /> I f <br /> � Fd mz <br /> MEL <br /> va a <br /> a on <br /> _. : . - m <br /> 0 o0 <br /> Z > n <br /> Q <br /> �....... ................... .�do <br /> Signature of Owner or Agent Date C <br /> X <br /> Remarks <br /> .................................................................................................................................................................... ................... — <br /> .......................................................................................................... ... . ~l <br /> ......... ........................................ . ' . . <br /> .............. ........ <br /> In <br /> InspectionDate ....................................... .. - . .....:.... . . ... ... ...................... <br /> onin9 mistrator m <br /> o sego oy <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 Inlstrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />