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Burnett County Office of Zoning Adminis rator d o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT µ 3 <br /> a ;4 <br /> o <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and to area as <br /> shown hlIf1er^^ein. The undersigned agrees that all work shall be done in accordance with the r/reeqquuiremen�ts of <br /> the Burnett County Land Use c <br /> OWNERclplease Sanitation tC �and with all other applicable County Ordinances and the CONTR rIaws and SUR�YORIations of or q(3ENThe State of WI cons'm. 3 Q O <br /> fl y►�5/ AKJ�. ..... ... ..... . . ... �/ C <br /> ................................................l .... X..`T�J�.. ...................._.............. a <br /> ADDRESS AD ssl r r ; <br /> ADDRESS............................................................................ ADDRESS <br /> w <br /> ...................................................................................... .. <br /> .. . ... ...E.............................................. <br /> .... .... ..... . . . . . . . . ...... ...... ....... .................................... : . <br /> PHON.E. ... .. .. . .......... .... ..... .... . . .. . .. . PHO....N <br /> . . ............................................................................................ <br /> PLUMBER WELL DRILLER <br /> ADDRESS ADDRESS <br /> o <br /> PHONE PHONE z N <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms ..... <br /> 2. New Building Details •• o <br /> New Building ..... .... Type of Construction: No. Bedrooms .......... �.` :Q ` <br /> Addition ...... ... .................................................... Septic Tank Size Gals. .........T� ,� /N <br /> Sanitary .......... Size .............. ft. x ft. ......... v <br /> Ruing,Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Soil Type ........................ ........... <br /> .......... ........................................... r <br /> o <br /> Mobile Home Slope .............................. ........... Ti 0 i <br /> .......... 1 <br /> Privy ,,........ 3. Use (describe exactly, 1 -family Pere. Rate ....................... ........... <br /> Well home,garage, motel, etc.) Dry Well _........ <br /> Subdivision Seepage Trench .......... <br /> Camping Unit ...... ... .................................................... Privy <br /> .................................................... Seepage Bed <br /> ---------------------- <br /> ------------------- <br /> -------------------------- <br /> Location of proposed structures and existing structures, well,sewage systems, goads, etc., should be sketched in Fig. A. Include. road o. <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highwY inter °- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. p <br /> _— I <br /> 5. Lot Size: <br /> Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — sq.ft. ................................................................... ........... <br /> {/I//nn11�11 C <br /> _M0 <br /> IN o <br /> vo .70 <br /> Qj <br /> � I s <br /> : I <br /> z <br /> 0 <br /> Mad r oa � w oa z <br /> C _. N C N <br /> < m C rrrr <br /> 2 0 o D n <br /> O aro <br /> Fr <br /> . ig. .......................r,"or."'ge, ................................. ...................................... 7th o � C <br /> Signature of Owner or Agent Date UUU — <br /> X 7L <br /> Remarks ............................................................................................................................................ rT <br /> T : : :.................... ........ m C <br /> M <br /> iky 11 <br /> .......................................................................................................... . .................... . ...... .. . <br /> Inspection Date ....................................... .. .. . / ,t. .i`^?� .. .. f!C.�...�3 . R�ig - o w o " rr <br /> Zoning Admini ator : .r`l. 0 0 0 0 0 U. <br /> W e J o 0 0 0 o rr <br /> NOTE: A preliminary site Inspection must be made and Ite approval granted on all structures involving sanita y facilities <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percoldtioi test must be attached to <br /> this application before a permit will be issued. Do not purchase or install a septic tank, do any pl robing or start any build- <br /> ing until a permit has been issued. A permit may be revoker) 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 he Zoning Administtatol . <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />