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Burnett County Office of Zoning Administrator <br />APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT <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 <br />Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. <br />01 6- 1 <br />4151 <br />�................n ............................... � �..................................................S..F........................................... <br />OWNER (please prifit) CONTRACTOR or SURVEYOR or AGENT <br />.......... 1. ... �... ,Z .... ........ ...14. u . ' � ....... 5 . .... . <br />ADDRESS ADDRESS <br />-So ...........T.....1..A.v....1.......l!�.�..t`?..!7............................................................................................ <br />ADDRESS ADDRESS <br />�E........................................................................................................................................................ <br />PHONE PHONE <br />...................................................................................................................................................................................... <br />PLUMBER WELL DRILLER <br />.............................................................................................. <br />ADDRESS ............................................................................. <br />ADDRESS <br />........PHO-H-ONE.................................................................................... <br />PHONE <br />DESCRIPTION 4. Sanitary Facilities: <br />1. Work: 2. New Building Details No. Bathrooms .......... <br />New Building ... Type of Construction: No. Bedrooms .......... <br />Addition FR f. r: 041 9/44 SeP tic Tank Size Gals. <br />Sanitary ... Size ...•r _4 ... ft, x �,Q.... ft. ......•••• <br />....... ...... <br />Filling/Grading .......... Height .....2...... Stories I..........4a. Absorption Field Site: <br />Moving .......... Area Soil Type .................................... <br />Mobile Home .......... Slope .......................................... <br />Privy 3. Use (describe exactly, 1 - family Perc. Rate ................................... <br />Well „�. home, garage, motel, etc.) Dry Well .......... <br />Subdivision .......... Seepage Trench .......... <br />Camping Unit .............................................................. Privy <br />.......... <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 />setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway 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. <br />____________________________________________ <br />5. Lot Size: .I O Ad ff $ Fig. A. 6. Location: C C C P1 0,Q b <br />................ ft. x .............. ft. — ............................... sq. ft................................................................................ <br />0) CD 0 z <br />o <br />3 <br />v rt <br />o <br />CD C N` <br />C <br />3 ° :-Z <br />N oID <br />CL ID <br />CD 7 <br />o <br />o « <br />Z <br />�^ r <br />0 0 0 <br />0 <br />CD <br />o <br />o • <br />I <br />c 6 C t�f [ 0 `J ';Z <br />a H C' <br />C- <br />LS <br />/��Ny�N <br />o <br />Id <br />CD <br />Z <br />�r o <br />CD <br />In <br />CD <br />- n <br />� CLD. Co <br />L = <br />ffl a <br />�. co <br />'� —• In <br />Z o o. �" a m <br />_3 a – <br />_ 7 <br />kri <br />-/ � ..... <br />�1. ... .............. � ......... 9 :::.. . <br />signature of Owner or Agent ,/ /s Date � � <br />3emarks................................../,..... ..?�,.t�/..G`!I.�Fta�...4?��G .4titie..C/ : : : <br />X rn <br />ID <br />T..y. �....«...................................................iNs�nF <br />-........................................�� ...............s.. <br />............. 5..% -.!�! .?.................................................... .. ;o l <br />...... <br />nspection Date.......................................%J!^%.....................%!............ <br />o• � <br />"� �N���Nm <br />ocnocnocnm <br />Zoning Administrat r </ 0 0 0 0 0 0 N <br />OTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br />afore construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br />its application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build - <br />g until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br />ith 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 />