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Burnett County Office of Zoning Administrator 10 $ gamg) <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT x 3. 3 <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 o c '� <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and B. <br /> regull�t/ionsofthe Stat of Wisconsin. <br /> ....R Ll......�Z...'skC.nok.................................. f. O.Q:lj......Uage 1....................................... F <br /> o <br /> w <br /> OWN/E�,R (plesse pr* tl COPIRACTO I or SURVEYOR or AGENT <br /> .......141.Q.w ...� .r............................... .....I�.�.a.....l..f....��.x....�f.l..................................... <br /> AD ESS AD SS <br /> .:.,...CYL! .........f.�..4.. ............................. . .. Iran.,.....Lis..... ��,........................ : t <br /> ADORE ADDRESS <br /> .......... <br /> ........................................................................................... ...PH.. ..E....................................................................... . <br /> PHONE ON... <br /> ........................................................................................... . . . ....... . .. . ....................................................................... '?�� <br /> PLUMBER WELL DRILLER � • <br /> ADDRESS ADDRESS <br /> . . . . . .................................................................... . ................................................................................... O .' <br /> PHONE PHON........E Z J B <br /> DESCRIPTION N r <br /> 4. Sanitary Facilities: ° o » S� <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details •••••• •• e <br /> New Building .......... Type of Construction: No. Bedrooms .......... � <br /> Addition .......... .................................................... Septic Tank Size Gals. .......... i ? <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... <br /> Filling/Grading ........ Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area Soil Type .................................... r <br /> Mobile Home .......... Slope .......................................... 0 <br /> Privy3. Use (describe exactly, 1 -family Perc. Rate ................................... i <br /> Well home,garage,motel, etc.) Dry Well .......... <br /> SubdwlalonSeepage Trench 0 <br /> ........................................I........... .......... o <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. <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. Z <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> _________________ __ __ _ __—____-- <br /> J <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ....... sq.ft. <br /> A f C+woL CS L 5V <br /> Vol I Ides <br /> J <br /> l 10 <br /> M <br /> Z <br /> O <br /> A <br /> W <br /> J <br /> M <br /> N <br /> N C 7 N d A <br /> In a '— nm aam <br /> O < v C y O J 3 <br /> y C N O b m <br /> Z <br /> o o D —1 <br /> a <br /> tnn ; y <br /> o <br /> C o p <br /> J <br /> � C <br /> m S <br /> g ................... .. ...................................... ;< A : O <br /> Signature of Owner or Agent Date o <br /> o , <br /> y <br /> Remarks ......................................................................................................................................................................... m <br /> o . . <br /> .......................................................................................................................... 8 : $ <br /> ............... <br /> 0 <br /> Inspection Date ....................................... ... �. 7l ..... .. .. ... . v, N (l� O O N <br /> Zoning Adminis r for ) 8 8 8 8 8 8 fmA <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities 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 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 />