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z lcn�y� <br /> Burnett County Office of Zoning Administri itor <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and M <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements o the n <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 S <br /> regulations of the State of Wisconsin. n <br /> JDA N.i.E L... .:..Z..►...n..n. .:�.................... .... ... ..�1.:......:�.'. ............. ....... A <br /> OWNER (please printl CONTRACTOR or SURVEYOR or AGENT <br /> 1� ..........1r1.�..,t S.7 t...1 .......... �!........s........ ..l R. ..... .z3.. ..7.. ..T ..............!,�...(..... ....I <br /> ADDRESS ADDR S = i �" <br /> was rt.. ................ .................. ................................................................. ....... <br /> ADDRESS �,.� -� r�j - ADDRESS <br /> ................ ............t'T.I.li!!.�...>.lr..!f.W✓..�........... ............. .............�Y..`.'.. ... ....... ....................................... ...... <br /> PHONE . Q11 <br /> PHONE .J CQ <br /> ......................................................................... .... ....... ...... ............................................................. ....... <br /> r- <br /> PLUMBER WELL.. DRI.. LLER.. <br /> O L <br /> ADDRESS ADDRESS m 0 :- <br /> < I V <br /> ........................................................................................... .................................................................................... ....... O .: <br /> PHONE PHONE Z N r. <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° 1- <br /> 1. Work: No. Bathrooms :S <br /> 2. New Building Details ""' c <br /> New Building Type of Construction: No. Bedrooms . ........ <br /> Addition ... „[�/, -!�!,-,,,q,q.Aj,'.T I•o.p) Septic Tank Size Gals. . ........ <br /> Sanitary .......... ....../.2-ft. x ...-3AO.. ft. . ........ <br /> ......... i ' <br /> Filling/Grading .......... Height............. Stories ...../........ 4a. Absorption Field Site: Q <br /> Moving Soil Type ........................... ........ <br /> .......... Area ........................................... i r i <br /> - o <br /> Mobile HomeSlope ................................. ........ :-# ^ <br /> .......... <br /> Privy .......... 3. Use (describe exactly,'1 -family Perc. Rate .......................... ........ o :7 i <br /> Well .......... home,garage, motel,etc.) Dry Well . ........ a :. <br /> Subdivision r=� ) � Seepage Trench . ........ o <br /> Camping Unit .......... .................................................... Privy ..... <br /> ------------ -------- ---- ------ ---- <br /> ---- -- — — Seepage Bed — <br /> ---- --- -- X,• Z_ <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. R, c <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is Iota ed at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. y :p <br /> ------------------------------------------------------------------- <br /> 5. Lot Size: ya f�C-.'R t_S Fig. A. 6. Location: Q <br /> ................ ft. x .............. ft. . ............................... sq. ft. ..................................................................... ......... <br /> J :; <br /> N O <br /> O = <br /> J <br /> iV <br /> E r!ou5r <br /> o <br /> P m O <br /> Z <br /> II D <br /> � - <br /> IN <br /> _ 0 <br /> /a rn.D R1 <br /> O m c v m m 0 m m M <br /> n ' cr < J - o - - m <br /> m t0a� - am F, FL <br /> G C <br /> O d y J J ; <br /> J, TU Aro <br /> U) <br /> -. D n <br /> G2 ,....�.....,,,....... ...Jc...l. ... .�.. ....... <br /> c <br /> M <br /> // > O <br /> Signature of Owner or Agent Date <br /> Remarks y <br /> v <br /> ............................................................................................................ ..... .... ...................................... ...... <br /> Inspection Date �C'(/ N N ' N m <br /> ....................................... ... .......................... ..................... N N N O (T m <br /> .............. ..... <br /> Zoni Administrator 8 8 8 8 8 8 in <br /> NOTE: A preliminary site inspection must be made and site approval 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 AF PROVED. <br />