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Burnett County Office of Zoning Administrator d - -{ z <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^ <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use c <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 0. <br /> a 0 <br /> 1 — m <br /> 6.pry ....... ....... .�1.................................. .................. ........ ................................................................ N <br /> : <br /> fi <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT m :rb <br /> S <br /> ik.lcl.d............. ......................................................................................... d <br /> ADDRESS ADDRESS m <br /> n . y ................................................................................. <br /> ADDR <br /> ESS'1............ ......r............ .5. 7•.�.................... ADDRESS <br /> ...................... .................................................................... ............................................................................................ •1L <br /> PH <br /> E PHONE <br /> . . . .! .... ...h..�..n.. r <br /> PLUMBER WELL DRILLER i <br /> ........................................................................................... .ADDRES.. .. ..S.. <br /> . ...... ............................................................................ <br /> ADDRESS <br /> m O <br /> n O <br /> . . . .......... ................................................................... . . . . ......................................... .......................................... <br /> PHONE PHONE o ' <br /> ...... � <br /> Z H r <br /> DESCRIPTION 4. Sanitary Facilities: / P o ° <br /> 1. Work: 2. New Building Details No. Bathrooms G o <br /> 0 <br /> New Building ......,,,. Type of Constru uoq: No. Bedrooms ..... Il <br /> Addition �,x<. /,•!-,, Septic Tank Size Gals. <br /> .............. <br /> Sanitary . Size .............. ft. x .............. ft. �..Q.O.. <br /> Filling ....... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Area Soil Type .................................... Y 1 r E <br /> ......... ........................... ............ . . <br /> o <br /> Grading Slope .......................................... <br /> Perc. Rate ................................... <br /> Mobile Home ,,,,,,,,,, 3. Use (describe exactly, -famil i <br /> Privy .......... home,garage,motel,etc.) Dry Well U� <br /> i - <br /> WellSeepage Trench .......... �� T <br /> ................................................... <br /> Subdivision .......... .......................... . Privy <br /> p 9 <br /> E <br /> ------------------------------------------------- See age Bed------- <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 ��" H� <br /> p' <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. ` , !,A' <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... <br /> 'Q tui <br /> m <br /> N 14 rt <br /> 7 <br /> 7 <br /> � •A ee <br /> :tom <br /> - tti <br /> 0 <br /> I" S <br /> -n �. <br /> 4. <br /> Z <br /> O <br /> , <br /> 7 <br /> m C cri o' CA m <br /> — 7 <br /> a Ol< <br /> G �?'NUl <br /> N <br /> b9 O <br /> O <br /> ........ ....... . ,................................. x.:13-�-3 _ <br /> Signature of Own or Agent Date — <br /> X <br /> € € € <br /> Remarks ...............................................................................................................: o <br /> m <br /> to <br /> ....................................................................................................... .... ................... .... ......................................... :4C� (Tl N <br /> /J <br /> InspectionDate ....................................... Q?'LL?..t...:..... ............ .. ............. 0 0 0 0 0 o m <br /> Zoning Atrator 0 0 0 0 0 o r/3 <br /> VOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> )efore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> :his application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> ng 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 Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />