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I',rnett County Office of Zoning Administrator 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> TO THE ZONING ADMINISTRATOR'. The undersigned hereby makes application for a Permit for the work described and located as '� — Oµ <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 /> o <br /> .............. .Q. ... ,.......Fr... ..� r................. ............................................................................................ <br /> �/ <br /> OWN /� <br /> ER Iplease print) / CONTRACTOR or SURVEYOR or AGENT <br /> ....XJ....... .c.X...2.5..........Z.r..^..�b!:o,F.��S .l !.+..:.... . . ...... . ............................................................................... <br /> ADDRESS 11–Syq/ ADDRESS V` <br /> ........................................................................................... ............................................................................................ TJ`I <br /> ADDRESS ADDRESS <br /> : <br /> PHONE................................................................................ .PHONE................................................................................ <br /> ............................................................................................ <br /> ........................................................................................... I <br /> PLUMBER WELL DRILLER <br /> ........................................................................................... ............................................................................................ n p <br /> ADDRESS ADDRESS LD <br /> n <br /> ........................................................................................... .PH....O...NE.................................................................................... 'z o .: <br /> PHONE � <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms .......... - o <br /> New Building .......... Type of Construction: No. Bedrooms .......... z <br /> m <br /> Addition .......... .................................................... Septic Tank Size Gals. .......... < {� <br /> Sanitary ,,,,,,,,,, Size ft. x ft. <br /> .............. ..... ........ <br /> FillinglGrading .,..,.,,,. Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... <br /> Soil Type ......................... <br /> $OPe ..................................................... � <br /> Mobile Home r0 <br /> ....... .. <br /> Privy ,,..),(.. 3. Use (describe exactly, 1 -family <br /> Pere. Rate ................................... O <br /> y <br /> Well .......... home, garage, motel, etc.) Dr Well .......... y) :\ <br /> subdivisionSeepage Trench .......... <br /> .......... .............................................. ..... <br /> Camping Unit Privy .......... I <br /> .................................................... Seepage Bed <br /> --------------------------------------------------------------------- <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched In Fla A. Include road (�J <br /> setback, side and back yard dimension and location and setback from all bodies of water. I1 property Is located at a highway inter- 1i a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL. EXISTING <br /> STRUCTURES AND PROPOSED STRUCTURFS AND ADDITIONS. <br /> o <br /> -------------------------------- G <br /> 5. Lot Size: 98 oCe Fig. A. 6. Location: A <br /> .../....... ft. x .3.,50.. ft. -- ............................... sq. ft. � <br /> O >' <br /> C ti <br /> ? N <br /> N a O <br /> O � <br /> P � <br /> W <br /> �G 1 CSGaI <br /> � t f <br /> a I N <br /> Prtr y y.aKe <br /> v X� f T O <br /> T r � o < <br /> w <br /> e o <br /> X N 7 M N W Z <br /> N I d a W <br /> D <br /> on <br /> Sam <br /> Z oo ng77 <br /> ffi <br /> ... z /........ .. 7-5... vD p <br /> Signature of Owner or Agent Date <br /> X <br /> Remarks ......................................................................................................................................................................... m m <br /> O <br /> ................................................................................................................... <br /> u ' <br /> ............................................................................................................ <br /> Inspection Date ` �` N N o m <br /> ....................................... ..... . ...... ................9... ...... ...................... <n o <br /> Zonin dministrator :) : 8 8 8 8 8 !n <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involVing Sanitary faCi iUaS <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 of specifications shall not be made without approval of the Zoning Adminlstratol . <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />