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Burnett County Office of Zoning Administrator d I o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. <br /> 0 � <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as '� H µ \v <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use C <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsinzz <br /> . — a <br /> H \� <br /> / .. ... ' .................................... .. I'�t .. .:.... 'we ,aaxl............................ Cc <br /> OWNER (please print) CONTRACTOR or SU RV EV OR or AGENT m <br /> n <br /> ........................................................................................... .............................. ............................................................. d <br /> ADDRESS ADDRESS <br /> ........................................................................................... .ADD......RES"'E'S"S.............................................................................. \l11 <br /> ADDRESS <br /> . . . . .................................................................................... M <br /> PHONE PHONE ?C�** ? :`^^•, <br /> ........................................................................................... WE. . LLD. .......R.I..LLER........................................................................... <br /> PLUMBER <br /> ........................................................................................... ............................................................................................ O <br /> ADDRESS ADDRESS <br /> n ° ; <br /> 0 < <br /> ........................................................................................... .PHON'H'0—...E.................................................................................. O r <br /> PHONE Z H <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms '9 <br /> 2. New Building Details o <br /> New Building Type of Construction: No. Bedrooms .......... <br /> addition .......... .....................I.......I...................... Septic Tank Size Gals. .......... <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... <br /> Filling/Grading .......... Height............. Stories ............... <br /> 4a. Absorption Field Site: <br /> Moving <br /> Soil Type ..................... <br /> .......... Area ........................................... ................... r <br /> Mobile Home $lope ............................ ..... . .... ° <br /> i <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Well ... home,garage, motel, etc.) Dry Well .......... i <br /> Subdivision ,'/,,, Seepage Trench .......... 1 <br /> .................................................... <br /> Camping Unit .......... Privy <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- a <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 /> o' <br /> ------------------------ <br /> Lot Size: Fig. A. 6. Location: <br /> ........I....... ft. x .............. ft. . ............................... sq. ft. .............................................................................. IN. <br /> s <br /> o <br /> ✓�� aepa3 -7 .139, x39 <br /> rte, <br /> Nt <br /> l Z <br /> j csl c, C' <br /> r L m m Z <br /> m a s = m n m <br /> Z <br /> 0 n ° <br /> _ m � <br /> :\ o O <br /> Aa 0 70 <br /> a <br /> m <br /> ................f ........r' 'o-r... . . .. C <br /> Signature of Owner or Agent Date iUti� C <br /> X 70 <br /> m <br /> Remarks ......................................................................................................................................................................... <br /> m <br /> v <br /> u <br /> ...................................................................................................... ... <br /> N N + m + N m <br /> ............. .............. .... .......................................... <br /> InspectionDate ....................................... ,C �. ................... ....!`J....................... : U U O N O N <br /> Zoning Administrator KJ 'c 8 8 8 8 8 8 N <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 t e made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />