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Burnett County Office of Zoning Administrator d 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. o <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 m <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. d ,� <br /> . ...... . . . .. <br /> OWNER (pleease t) CONTRACTOR or SURVEYOR r AGENT m . <br /> o <br /> ............................... . .................................................................. ....................... <br /> ADDRESS............................................................................ ADDRESS <br /> . . ...... . ............................................................................... .W <br /> ADDRESS ADDRESS <br /> PHONE................................................................................ .PHON..E................................................................................ <br /> ........................................................................................... . ................ . ....................................................................... •\ <br /> PLUMBER WELL DRILLER <br /> ........................................................................................... <br /> ADDRESS . .......................................................................................... <br /> ADDRESS m <br /> n 0 O <br /> PHONE PHONE 'Y <br /> 1— <br /> DESCRIPTION 4. Sanitary Facilities: °x o ° <br /> 1. Work: 2. New Building Details No. Bathrooms <br /> .......... :o 0 <br /> New Building No. Bedrooms •'� ° <br /> .......... Type of Construction: ••••••• •• 'a $ <br /> Addition ,,.,,,,,•• Septic Tank Size Gals. :F <br /> ...................... . ................... .. .......... .� <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... :A <br /> FillingfGrading •„••,,,,, Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Soil <br /> Type .............................. ...... o.......... ........................................... ................ . <br /> Mobile Home .......... Slope ........................ r <br /> i <br /> y <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> wellhome,garage, motel, etc.) <br /> Dry Well .......... w <br /> .......... <br /> SubdivisionSeepage Trench .......... x; <br /> .......................................... ......... <br /> Camping Unit „........ Privy ......... to ' <br /> .................................................... Seepage Bed ......... <br /> —_ _ ___________________________________________ w <br /> ----- . 1l <br /> ___ (� <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig. A. Include road O '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- o- <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. H. <br /> A <br /> ______________________________________ p 1 <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq. ft. ............................................................................... <br /> 01° <br /> N <br /> ° O O <br /> s <br /> Z <br /> ° <br /> r 9 N W 2 <br /> 0or <br /> {p <br /> 9 lN1r O. C m <br /> Z 00 m D a m <br /> ow= 'n m 3 <br /> — <br /> (�C' <br /> p <br /> Signature of Owner or AgentDate0 a <br /> X <br /> Remarks ......................................................................................................................................................................... <br /> ............................................................................................................ <br /> ........................................................................................................... . .................................... .. ............................... :a <br /> :Qc <br /> Inspection Date (////j�..'�.'. ` F r.� "' m N m <br /> ....................................... .l.j.. ............. ...:....... 9...... . . ... ..........�.............. : .I Ili N 8 N O N <br /> ✓/J' Zonin Administrator J 1 8 8 8 8 8 8 11 <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 bz made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />