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Burnett County Office of Zoning Administrator 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT - 3. <br /> d <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < — o ;res <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use no <br /> Ordinance,ISaniittattion `Code,and with all other applicable County Ordinances and the laws and regulations <br /> of the State of Wisconsin. 3 <br /> `!ti2CeG(/....... L!!Gipo;ew. . .... . ........................... `� O <br /> ........................... ` <br /> OWNER/(Please print) CO FACTOR or SU EYOR or AGENT <br /> ...................... J A.................... . ..a.... ... ..i......z........................................ d ,� <br /> ARDDRESS AD ESS (� <br /> ;1�,[•Qo,!!,•>,�v,�•ron/.,..r!':!N..........4ssyr?.7.............. ,, t.... .�. ...... ....f G /....SAY°-?..4�....... <br /> ....... <br /> ADDRESS ADDRESS <br /> :1J <br /> ........... <br /> ........................................................................................... .PHONE................................................................................ <br /> PHONE [� <br /> ........................................................................................... WEL. . . <br /> L DRI.LLE. . ..R.................................................................... :r <br /> PLUMBER IVB ;� <br /> O <br /> .......... <br /> ........................................................................................... . ..... .................................................................... _. <br /> ADDRESS AD.. DRES......S m 0 <br /> � o <br /> ........................................................................................... . ................................................................................... o' <br /> PHONE PHONE........ Z H ' <br /> r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> :a <br /> 1. Work: 2. New Building Details No. Bathrooms .......... o ; <br /> New Building No. Bedrooms " a irJ7 <br /> .......... Type of Construction: ......•• 3 <br /> Addition Septic Tank Size Gals. .......... F ;� <br /> .......... ...................... . ................... .. .� <br /> Sanitary .......... Size .............. ft. x ft. .......... <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Soil Type ....................................Moving .......... Area ........................... ............... ' r <br /> •_'1 o <br /> Mobile Home Slope .......................................... <br /> .. <br /> Privy ,,,,,,,,,, 3. Use (describe exactly, 1 -family Perc. Rate ................................... � <br /> Well .......... home,garage, motel, etc.) Dry Well .......... <br /> Subdivision ,✓„ Seepage Trench .......... <br /> .................................................. r•D <br /> Camping Unit Privy .......... <br /> Seepage Bed .......... <br /> Location of proposed structures and existing structures well, sewage systems, roads etc., should be sketched in Fig A. Include road ( C <br /> 0 a <br /> setback, side and hack yard dimension and location and setback from all bodies of water. If property is located at a highway inter W _ <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING < <br /> e <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. p' <br /> ________________________________ _____ <br /> 5. Lot Size: Fig. A. 6. Location: 0 <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... <br /> P <br /> n <br /> N O <br /> 0 <br /> T <br /> Cj Z <br /> (� O <br /> N <br /> ,. <br /> :0' <br /> � �M r mmz <br /> m <br /> -' m <br /> Z <br /> 0 <br /> Signature of Owner or Agent Date i o C <br /> X <br /> Remarks ......................................................................................................................................................................... m m <br /> M o <br /> ....................................................................................................... ... ..................... ... ....................................... <br /> Inspection Date m <br /> 27i;?�o/. ....... a o P, o m <br /> Zoning Admi istrator J i $ $ $ $ $ $ $ m <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 he 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 he made without approval of the Zoning Adm inistrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />