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Burnett County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY — LAND USE ��eILDING PERMIT 3 <br /> �^.'_ r� o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application or a Tf ApR, ork described and M ;d <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance-wit �p�p� of the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and''tl' Jj&d 3 a <br /> regulations of the State of Wisconsin. a 3 <br /> Richard Engstrom <br /> OWNE..R...I.p..l.s.a..s.e............. ..... ......................... . ... ..�t. � ........ .. y. �. 4d <br /> ED <br /> .......................... „•„,,.. <br /> print) 0c %o ......... ...... ..... .CONTRACTORorSURVYOR v <br /> or AGENT <br /> Siren WI 54872 <br /> A...D..D.R.E.S..S...................... ... . . <br /> ` ............ ............... <br /> ADDRESS.................................................... cb <br /> . ........................................................................... .A.......RES.................................................................................... 0 <br /> ADDRESS DDS � n <br /> 7.?.5-349-5887 <br /> l�0 i w <br /> . . . ........................................................ ................................................................... <br /> PHONE PHONE _ _ c-G �- <br /> Donald Daniels 1S- S 'V9-u a97 <br /> .................................................................. ............................. <br /> .......................................................... <br /> PLUMBER WELL DRILLER -v Orq <br /> Box W Siren,,,,WI....•54872 7 <br /> .. . . c ~ <br /> ADDRESS ADDRESS ) : O <br /> 715-349-5364 ” d ` E1 <br /> .. ....................................................................... . . ....................................... ....................................... <br /> PHONE P..H..ONE.... .. Z N r <br /> DESCRIPTION 4. SanitaryFacilities: P o <br /> No. Bathrooms T ' <br /> 1. Work: 2. New Buildin Details "�"""' o <br /> 9 No. Bedrooms 2........ i— <br /> New Building „4,,,, Type of Cons r Von;A�t Septic Tank Size Gals. ].DDA. E— <br /> Addition .......... ................... fJ"".................. :� i C <br /> Sanitary Size .. .�..... ft. x .... """"" <br /> .......... p .J.P.... ft. <br /> FIIIIngfGradlnq .......... Height......F.... Stories ..../......... 4a. Absorption Field Site: <br /> Moving .......... Area 7caS� ~ Soil TYPe .................................... r- <br /> ............. . ...... .... ........ o <br /> Mobile HomeSlope ..............4........................... <br /> .......... <br /> Privy 3. Use (describe exactly, 1 -family Perc. Rate ...........................3 •• 0 it <br /> Well .......... home,garage,motel, etc.) Dry Well .-...... - 't , <br /> Seepage Trench <br /> Single famil home • ••••• • o y <br /> Subdivision .......... ........... ...................Y................... p <br /> Y <br /> Camping Unit Priv .... ..... -j <br /> Seepage Bed Mound '--- l4 o <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. U� N <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. : 1 ` t- <br /> -———————————— <br /> ------------- _____ _ Q <br /> 5. Lot Size: Fig. A. 6. Location: 'L {D <br /> .I <br /> ................ ft. x .............. ft. - ............................... sq.ft. ............................................................................... <br /> N i( O <br /> G <br /> �o `1 RIi <br /> 0 <br /> See State approved Plans m. <br /> 0 <br /> r..i <br /> T >O <br /> :z <br /> Z <br /> 0 <br /> :1 n <br /> rn <br /> E <br /> fA � f/� r DiP IP <br /> w Q < > > n m <br /> m Nnc - nm nny <br /> 9 < d C <br /> 8M Q 0 <br /> Z D � -1 <br /> 2s � S �7.......... <br /> Signature of Own.. er or A t Date S <br /> V <br /> Remarks <br /> ........................................................................................................................................................................................ <br /> 9J S <br /> Inspection Date ....................................... .... <br /> � . .. .. ..ri OI v N D o T <br /> Zoning Administra c? S 8 S S <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 />