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Burnett County Office of Zoning Administrator �' o <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT3 V <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 'z p 1-•C <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws nd 3 . <br /> regulations of the State of Wisconsin. <br /> Gerald Thompson # n <br /> .............. .............. ..................................................... ..................................................................................... ...... <br /> QWNER (please print)......... CONTRACTOR or SURVEYOR or AGENT W s <br /> Twin Pines Trailer Court <br /> ..... . . . ............................................................................... . ......... ....................................................................... ...... <br /> ADDRESS A..DDRES..S = \ r-, <br /> Hugo+ MN 55038 <br /> ......... ................................................................. ...AD...DRES.... ..S.... ..................................................................... ...... <br /> ADDRESS <br /> PHONE PHONE it � 0 <br /> DonaldDaniels ..................................................................................... ...... <br /> PLUMBER............................................................................ WELLDRI LLER 0 <br /> Box W Siren. .WI,.,••, 48.7.2 ' <br /> ..................................................................................... ...... v <br /> ADDRESS ADDRESS a G <br /> .. ........................................................................................ ..................................................................................... ...... O " <br /> PHONE PHONE Z N r <br /> DESCRIPTION 4. Sanitary Facilities: c <br /> 1. Work: No. Bathrooms ....2.... <br /> 2. New BuildingDetails o <br /> Naw Building ,,,,,,,-„ Type of Construction: No. Bedrooms .. ...... <br /> Addition Septic Tank Size Gals. 12. 0•••• ,7 ' <br /> .......... .................................................... <br /> Sanitary .....X... Size .............. ft. x .............. ft. .. ....... <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: i <br /> Moving .......... Area Soil Type ............................ ....... o <br /> Mobile HomeSlope .................................. ....... <br /> .......... i <br /> Privy .......... 3. Use (describe exactlyPerc. Rate .....................I..... .,'1 -family """ <br /> Well ...•••.... home,garage,motel, etc.) Dry Well .. ....... x i <br /> x ' <br /> Seepage Trench Z <br /> Subdivision " "' ' x <br /> Camping Unit <br /> Privy W x <br /> x.......... .................................................... Seepage Bed <br /> g Mound .. .... <br /> Location of proposed structures and existing structures well, sewage systems, roads, etc. should be sketched in Fi . A. F <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is local d at ' <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersec ion. Qj) „<—, <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. v ,Y <br /> __________________________________________ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq.ft. ...................................................................... ........ <br /> 0 ' <br /> n <br /> N <br /> M <br /> � o <br /> SEE STATE APPROVED PLANS n <br /> o "• <br /> 0 <br /> 0 <br /> :7n : a <br /> I <br /> M W <br /> N <br /> z <br /> Z <br /> 0 <br /> r p <br /> I y <br /> e <br /> m <br /> M <br /> c m w N n to C <br /> In <br /> m Nci <br /> D - 1 <br /> o <br /> 2 a ' <br /> o c o m <br /> ........................................................................... ...................................... y <br /> Signature of Owner or Agent Date $ <br /> Remarks n <br /> .................................................................................................................................................................................. ..... <br /> 0 <br /> a . . <br /> ......................................................................................................... ...... .......Av� <br /> .Inspection Date ....................................... .. ............. .................................. ..... v, N (T O O U1 mministrator 8 8 8 8 8 8 fA <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary f ilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this app !cation 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 ANDA PROVED. <br />