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QTl , '-'�(_�' <br /> Burnett County Office of Zoning Administrator0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. o <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 /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. <br /> llfw4e* ...�� ....................................... fit' / µ <br /> OWNER IPIease Printl CONTRACTOR // y....••••.•.••••.•.•...........••••. N <br /> ... . ...... ... ... ............ . . . . ....J.....L4.•..�..i...J.i.:.. _ <br /> or SURVEYOR or AGENT a <br /> ........................................................................................... . . ...... . ............................................................................... d J <br /> ADDRESS ADDRESS <br /> ........................................................................................... .AD.. DR......... .............................................................................. . <br /> ADDRESS ESS.. <br /> ........................................................................................... ............................................................................................ - <br /> PHONE PHONE <br /> ........................................................................................... ............................................................................................ <br /> PLUMBER WELL DRILLER <br /> O <br /> ADDRESS ADDRESS0 LD <br /> ti o <br /> ........................................................................................... . ..................................................................................... 0 .i <br /> PHONE PHO......NE Z h <br /> r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms o <br /> New Building •........• Type of Construction: No. Bedrooms .......... i� <br /> Addition .......... .................................................... Septic Tank Size Gals. .......... i < <br /> Sanitary „........ Size .............. ft. x ft. """"" <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: i <br /> Moving .......... Area ........................................... Soil Type .................................... r <br /> � <br /> Mobile Home .......... Slope ....................... o <br /> Perc. Rate ...................................................... <br /> t� <br /> Privy ,,........ 3. Use (describe exactly, 1 -family .� <br /> Well ... . home,garage, motel, etc.) Dry Well .......... <br /> g <br /> Subdivision <br /> Seepage Trench .......... 21i. <br /> ......•... <br /> Camping UnitPrivy <br /> .................................................... Seepage Bed <br /> .......... <br /> Location of proposed structures and existing structures,well, sewage systems, roads,etc., should be sketched in Fig. A. Include road <br /> 0 <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 <br /> a <br /> " RUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. p' <br /> ___ <br /> . Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... <br /> e <br /> :5 <br /> JG� ✓J _l 0 <br /> N O <br /> 0 7 <br /> fbl, 11 - Ido z o <br /> iMr <br /> v 90 a <br /> 7a r 9 m m Z <br /> C j 0 C N <br /> Aj cNn < = mm <br /> m <br /> z oo ys <br /> o a' 3 <br /> vi - <br /> .� <br /> 0C, <br /> ........................................................................... ...................................... V o . C <br /> Signature of Owner or Agent Date :�I — <br /> X <br /> Remarks ......................................................................................................................................................................... <br /> 'C v <br /> .......... ...................... <br /> ..................................................................................................... ............... �1 II <br /> 18 " m <br /> �} � j!N .................................... <br /> .13 NN m Nm <br /> Inspection Date ....................................... .i/s..'!Z?.LCf..l.... .....,/„iLfL.... ....�..✓....................... fn a o ui o rn <br /> Zoning Admi Isf trator CU 8 8 8 8 5 8 vi <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 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 be made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />