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-04 <br /> Burnett County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT ;; <br /> I <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and M <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the c <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and <br /> reguAions of the Stateof Wisconsin. 3 a <br /> Q(. ............................ ....................................................................................:....... A 3 <br /> OWNER (please pr' tl CONTRACTOR or SURVEYOR or AGENT <br /> ............... <br /> ..I..,... Qx.... 3x.'.............................. ..................................................................... <br /> ........ d 7C r4..D .Ess <br /> �'."7...{....Y,`f- ..... 'J...! ...................... ADDRESS <br /> ............................................................................ �J <br /> ADDRESS ADDRESS <br /> ........................................................................................... .................................................................................. ON i <br /> ........... <br /> PHONE PHONE <br /> ............... <br /> ........................................................................................... .W.EL. ..L...D.RIL.. L......ER........................................................ :W <br /> PLUMBER <br /> ........................................................................................... .AD......D.....RES................................................................................ <br /> AOORESS S m <br /> ^ < <br /> 0 <br /> . <br /> ........................................................................................... .....PHONE..... ......................................... ....................................... o <br /> PHONE <br /> 0 r <br /> DESCRIPTION 4. SanitarYFacilities: ° o » —� <br /> 1. Work: 2. New Building Details No. Bathrooms .......... c :�- <br /> New Bwldmg .,, Type nstru�ct�i ` No. Bedrooms .,........ ' <br /> Addition ...... lug •.. J� Septic Tank Size Gals. .......... <br /> .......... <br /> Sanitary Size ... .y.. ft. x .. .L'„i.. ft. •• •• • • <br /> Filling/Grading .......... Height............. Stories ..... ........ 4a. Absorption Field Site: <br /> Moving .......... Area ..................... Soil Type ...........................:........ <br /> ...................... <br /> o <br /> Mobile Home .......... Slope .......................................... <br /> Privy .......... 3. Use (describe exactly,"! -family Perc. Rate ................................... 2 � <br /> Dry Well � <br /> .......... _ c <br /> Well ,,,,,,,,,, home,garage,motel, Seepage Trench o `• `p <br /> Subdivision .......... ' <br /> Camping UnitPrivy <br /> .................................................... Seepage Bed <br /> i <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. = <br /> --- <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. ( o <br /> -- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. .....................................................................,......... <br /> 0 <br /> o f. T <br /> o <br /> d <br /> � � a - - m <br /> N NEL QN a21J <br /> y <br /> � Comm3 <br /> o wo D 1 <br /> o » o : O <br /> c <br /> m <br /> Signature of Owner orr�AgenF ,Q,Q"/�n/� Date ,r�'�n /., ! Q�y/ � $ <br /> Remarks ......`s�. ,....... 1..!1-/!. .i!.1.(��i.. .cS .rJ... ....l..r:�`:. .. .....'`.!....rte'.....�l.0...................... <br /> m <br /> o <br /> h O <br /> ...................................................................................................... ..... . ............. .. ................................... .............. <br /> O ' O <br /> O <br /> Inspection Date ....................................... ... ....!71.0%l.,. . 7 .TlA. .............. N N N OOn <br /> Zoning Administr or $ 8 $ $NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities before constructs <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 been 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 />