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Burnett County Office of Zoning Administrator �' e <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT V #. <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 the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws Ind 3 <br /> regulations of the State of Wisconsin. g <br /> .hn...t?anl.t .t.. Ma....i4.... .. ................................... ...... A <br /> OWNER (please print) G CONTRACTOR or SURVEYOR or AGENT <br /> ADDfjS$.�.. ...!.! ..... ....J............................................... .ADT....-5.....4�............................................................. ...... d <br /> .kla�ur ...?moi ��E/nS ^rK�Iy �y�y(y� <br /> ........1.....::1 .......I.l.. ... .ADDU.U.0 ti.�:�?":?:'!...�... .....-L.LSJ.. ,l................ ...... ? ''.� SY . <br /> ..................................... <br /> ADDRESS <br /> ........................................................................................... ..................................................................................... ...... <br /> PHONE PHONE <br /> ........................................................................................... ..W..EL..... <br /> L...D.RIL.. L......ER ............................ .................................... ...... <br /> PLUMBER <br /> ....... ...... <br /> . . . ................................................................................ .ADD.. .. RES. ..R.E'S"................................................................ <br /> AOORESS S 0 C <br /> c <br /> ........................................................................................... ...................................................Y................................ ...... G <br /> PHONE PHONE Z „ r <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> 1. Work: No. Bathrooms 0 �Q <br /> 2. New Building Details " '•""' c 1� <br /> New Building .•,,,... . Type of Construction: No. Bedrooms .. ....... <br /> Addition .................................................... Septic Tank Size Gals. .. ....... <br /> .......... <br /> Sanitary Size .............. ft. x .............. ft. .. ....... <br /> Pilling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... AreaSoil Type ............................ ....... i o i <br /> ........................................... Slope .................................. . <br /> Mobile Home .......... ' ' - <br /> Privy .......... 3. Use (describe exactly,'1 -family <br /> Perc. Rate ........................... ....... <br /> Well Dry Well., ., home,garage,motel, etc.) " """' m— • <br /> SubdivisionSeepage Trench o <br /> .. ... .................................................... Privy .... i <br /> Camping Unit .......... .. """' <br /> .................................................... <br /> Seepage Bed .. ....... <br /> Location of proposed structures and existing structures well sewage systems, roads, etc., should be sketched in Fi I. A. :X_ i c �(-t-1 <br /> 1 " <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is local d at F <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. N <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. — 0 <br /> — ------------------------------------------------------------------ — O <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ......... sq.ft. ,Q) rn <br /> 0 J <br /> J <br /> �(o� II �ac �s �► �—��� o <br /> 0 <br /> O <br /> f <br /> T J <br /> I <br /> n I T <br /> J} Z <br /> O <br /> A <br /> a <br /> J <br /> e <br /> m <br /> m c � m m m m <br /> U m mrn <br /> Q 10 m <br /> Z o D 1 <br /> o y n . <br /> in 9 <br /> o p <br /> � J C <br /> m � <br /> A : m <br /> ........................................................................... ...................................... a <br /> Signature of Owner or Agent Date 8 O <br /> T : m <br /> Remarks n <br /> ....................................................................................................... ... ..................... ... ... . ................. ... .. s <br /> I \W�D .... <br /> Inspection Date ....................................... m <br /> :/.I.UF ....�.ning............... . ... ...... V7 N fT O O tP <br /> Zoning Adminis for � 8 8 8 8 8 8 fA <br /> NOTE: A preliminary site inspection must be made and site approval 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 application 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 bee i issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or specifications 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 />