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Burnett County Office of Zoning Administra or Iv' o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT x 3• o <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 he <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws nd 3 <br /> regu1l�tions of the State of Wisconsin. 9 <br /> I . fiY. ..................... ....!`..a..... ... :(.....S.u(Je�fa. 1.. ............................. ..... 3 <br /> OWNER Iple p 'ntl CONTPAICTOR or SURVEYOR or AGIINT <br /> .i... °.. ,... �....... ....ftx.... .............................................................. ..... a <br /> A ESS ADD ESS (T m t <br /> 4kq'l n.(� ' ,�\-r' I- l,�ql( �s-_eT 111 -- <br /> ...C..1.�.�.lel.1 .r....1/." :...... �..,Kl..................... ....Y.11k.!..............:....................................................... ..... i :Y✓ "� <br /> ADDRESS ADDRESSft <br /> ^ <br /> ....... ..... <br /> ........................................................................................... . ...................................................................... <br /> PHONE PHON........E <br /> ........................................................................................... .WEL.. ... .............. <br /> ILL.................................................................. ..... <br /> PLUMBER L DRER <br /> O <br /> ADDRESS ADDRESS0 o <br /> ^. c <br /> ........................................................................................... . ............................................................................. ..... 0 <br /> PHONE PHONE........ <br /> N <br /> DESCRIPTION 4. Sanitary Facilities: <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details c <br /> Now Building No. Bedrooms <br /> .......... Type of Construction: ••. •••••. - <br /> Addition .......... .................................................... Septic Tank Size Gals. ... ...... <br /> Sanitary .......... Size .............. ft. x .............. ft. ... ...... <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: E i <br /> Moving .......... Area Soil Type ............................. ...... i <br /> Mobile Home .......... Slope .................................I. ...... 0 <br /> Priv Perc. Rate ............................ ...... m <br /> Privy 3. Use (describe exactly, 1 -family 0 i <br /> Well Dry Well m i <br /> ,,,,,, home,garage,motel, etc.) "' """ — <br /> Seepage Trench z <br /> Subdivision t�-t�T ... ...... o <br /> Camping Unit .......... .................................................... Privy ... - <br /> Seepage Bed <br /> ------------------------------------------------------------------- <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig A. Q <br /> Include road setback,side and backyard dimension and location and setback from all bodies of water. If property is locatt d at o. <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. :� o <br /> __________________________________ —_______________________________ __ <br /> 5. Lot Size: Fi9A. 6. Location: Hi <br /> ................ ft. x .............. ft. — ................ sq.ft. ...... t • <br /> .............. ...................................................................... . r <br /> ^ ^,.�nl p^I C>:0 <br /> N O <br /> 0 <br /> ° <br /> N <br /> a <br /> T <br /> Z <br /> 0 <br /> ' D <br /> a <br /> J <br /> m n -' nm nny <br /> ° p 10 <br /> Z o �2 D 1 <br /> O J <br /> ma <br /> n : y <br /> o c m <br /> � 0 : 0 <br /> m C <br /> A : m <br /> ........................................................................... ...................................... <br /> Signature of Owner or Agent Date o <br /> Remarks C) y <br /> ......................................................................................................................................................................... <br /> m •• <br /> m <br /> ......................................................................................................... <br /> .... ...................... ... ..... . .. ...... ....... .... <br /> Inspection Date I N m N l N rMnT <br /> Zonin9Administrat 8 8 8 8 8 8 rn <br /> NOTE: A preliminary site inspection must be made and site appro I granted on all structures involving sanitary fa ilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this appli ation 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 beer issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or pecifications 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 />