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Burnett County Office of Zoning Administrator �' c <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3• <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the State of Wisconsin. = C '1 <br /> Q. ..�z.r..!'............................... ............................................................................................ H <br /> OWNER (pies print) CONTRACTOR or SURVEYOR or AGENT <br /> .4.11....'J7. .0.. r�.........lr,p..�.r.....%W-A.._....... . ...... . . ............................................................................... d <br /> ADDRESS ADDRESS . <br /> ..s..Y.. ......................................................... ............................................................................................ <br /> �r I <br /> ADDRESS ADDRESS i� 7 <br /> .............................................................................. <br /> PHONE PHONE _ <br /> R. ....> o.P.. . h...J.................................................. ............. ....................................................................... <br /> PLUMBER WELL DRILLER :K) <br /> ........................................................................................... ............................................................................................ O <br /> ADDRESS ADDRESS 0* o !{t <br /> 1 h <br /> ........................................................................................... ..P. ..................................................... 3. 'r <br /> Z.............................. <br /> PHONE HONE...... r <br /> DESCRIPTION 4. Sanitary Facilities: o c o ,d <br /> 1. Work: 2. New Building Details No. Bathrooms .......... c <br /> New Building .......... Type of Construc(�o n: No. Bedrooms .......... <br /> /j � Septic Tank Size Gals. 'jJ <br /> Addition .......... .......w...IL+.,� ........�..rl-t .. < <br /> Sanitary v............. 7X0. i�.l <br /> ..X... Size .............. ft. x .............. ft: 4a. Absorption Field Site: <br /> Filling/Grading .......... Height............. Stories ............. . VI`s <br /> ........ Type .................................... � i <br /> Moving .......... Area ........................................... Soil qa + o <br /> Mobile Home Slope ................................I......... .. <br /> .. m N <br /> Privy .......... 3. Use (describe exactly '1 -family Perc. Rate ................................... <br /> Well ....,,.... home,garage, motel, Dry Well .......... _ <br /> Seepage Trench o <br /> Subdivision •• <br /> i . <br /> ....... <br /> CampingUnit .......... .................................................... <br /> Seepage Bed ..!...... 'y <br /> ---- --------------------------------- ------ l in <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. :w :�. F r• I <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at �. <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. �L 1 <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> __________________________________ ___________________________________ .0 <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... <br /> ° <br /> N O <br /> O � <br /> _J <br /> 7 <br /> i <br /> O <br /> f <br /> J <br /> 17` •` <br /> T <br /> w <br /> N <br /> Z <br /> O <br /> ]7 <br /> a <br /> e <br /> mm � rnr Dmm � <br /> 1.1 m c . w 0 o c c <br /> o r cr < D_ ° o � � m <br /> LD W n� n m a a y <br /> O N < O <br /> Z_O .2 D <br /> (n n : S <br /> o c m <br /> V 0 <br /> � c C <br /> ...6,.�A.�.�..K..O.............. x > m <br /> ......... . ... . ...... . ............................................. — <br /> Signat re �O/wn/or <br /> Age <br /> nt Date $ <br /> Remarks ..1 . .. ..i...°...C.r17J.:... ......................................................................................................................... " l <br /> m '- <br /> v <br /> ............................�................—.....�.....8............................................. <br /> Inspection Date ^ ....... l I� <br /> � <br /> m <br /> for $ o $ ca <br /> NOTE: A preliminary site inspection must be made and site apprd4al granted on all structures involving sanitary facilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this application before a permit will <br /> be issued. Do not purchase or install a septic tank, do any plumbing or start any building until a permit has been issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />