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Burnett Count <br /> Y Office of Zoning Administrator d 0 o <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 <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 /> Ordina e, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the 3 fD <br /> 9 the of Wisconsin. <br /> a <br /> OWNER (Please print) ........................ <br /> CON ACTOR or SURVEYOR or AGENT � m o <br /> d X m <br /> ADDRESS AD R S �...f. ...L�..�................................ a <br /> ................. .......................................................... . ...14 . .r...,....[ .a...... ........................ <br /> ADDRESS ADDRESS <br /> ........................................................................................... <br /> PHONE . .......................................................................................... <br /> PHONE <br /> ........................................................................................... <br /> PLUMBER . .......................................................................................... <br /> WELL DRILLER c ; <br /> .................................................................... . .... .. <br /> . .ADD..RESS <br /> ......... . . .... . .. .. . ............................................................................... <br /> ADDRESS <br /> m 0 <br /> ................................................................................... ........ <br /> PHONE . . ..................................................................................... <br /> PHONE <br /> o <br /> DESCRIPTION o r- <br /> 4. Sanitary Facilities: o <br /> 1. Work: 2. New Building Details No. Bathrooms i v ~ <br /> .......... <br /> New Building Type of Construction: No. Bedroomso <br /> v 1 <br /> .......... a <br /> Addition Septic Tank Size Gals. ....... .. i <br /> Sanitary .......... Size .............. ft. x .............. ft. ........ <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Area Soil Type .................................... � <br /> Mobile Home ••........ Slope O <br /> Privy ........ 3. Use (describe exactly, 1 -family Perc. Rate ........................I.......... <br /> Well home,garage, motel, etc.) Dry Well <br /> Subdivision <br /> ... Seepage Trench .......... <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 Pig. A- Include road <br /> c <br /> setback, side and back Yard dimension and location and setback from all bodies of water. If properly 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 5 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> 0 <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq. ft. <br /> ............................................................................... <br /> m <br /> 49�� ej C,S u N <br /> 0 <br /> 11 Z <br /> I <br /> I � s <br /> ', i ill ✓'/v � � <br /> N <br /> J <br /> N <br /> N C j j ry <br /> m <br /> C C <br /> N <br /> z oN Dam <br /> b <br /> o � <br /> Inn <br /> O <br /> Signature of wner or Agent Dao : � p <br /> te 0 <br /> Remarks ......................................................................................................................................................................... Ti x m <br /> m <br /> .......................................................................................................... <br /> n <br /> Inspection Date ........................... ,�,�t �^ ' a v m <br /> ........ .... ..... ..:L1.1J:SJ�.. ......./..+-..... u " <br /> / ........ O orb <br /> 0" <br /> Zoning Administ a r : 'o 0 0 8 0 o co <br /> M <br /> NOTE: A preliminary site inspection must be made and ite 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 Ile made without approval of the Zoning Administratoi_ <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />