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Burnett County Office of Zoning Administrator �' o <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT ; �• <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 m t <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws nd •/��1' <br /> re illations of thy State of Wisconsin. 3. 'a <br /> . 5.„.4./... ........ ........................... ............................................................................................ <br /> OWNER (pleax print) ,/-, CONTRACTOR or SURVEYOR or AGENT ; <br /> ••/•1...G/�...(a..... .1AA..1''N...11 . 1�....���..................... ..................................................................................... ...... a <br /> ADDRESS V ADDRESS ;C7 <br /> ...�.. ....�6.. r�.[ K �(..... n...... <br /> ADDRESS kya....� ............ aN ADDRESS..................................................................... . <br /> NI ... <br /> ........................................................................................... ..................................................................................... ...... <br /> PHONE PHONE <br /> ... ..5............................................... ..................................................................................... ...... <br /> PLUMBER WELL DRILLER `;'�- 'Ln <br /> O <br /> ADDRESS ADDRESS n O :r? <br /> PHONE PHONE Z H ;r <br /> DESCRIPTION 4. Sanitary Facilities: Po » 'd <br /> 1. Work: 2. New Building Details No. Bathrooms ... ...... n c it <br /> New Building .......... Type of Constructs _ No. Bedrooms ...... L <br /> Addition Septic Tank Size Gals. ... ...... <br /> .............2..X1..3./..(.n.. ............ S <br /> 7 ...... <br /> Sanitary ....x... Size .............. ft. x .............. ft. <br /> Fillingf Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area .................................. Soil Type .................................... i :M o i <br /> '1 <br /> Mobile HomeSlope .......................................... ?4 .. <br /> .......... <br /> Rate ................................... <br /> Privy .,........ 3. Use (describe exactly '1 -famil Perc. � <br /> Well .......... home,garage,motel, etc. Dry WellSubdivision .. ....... ry `• <br /> .......... .................................................... <br /> Seepage Trench o CR <br /> Camping UnitPflvy .. ....... <br /> .......... .................................................... <br /> Seepage Bed / .y <br /> --------------------------------------------------------- -- <br /> P N <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. 'm <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is local ad at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. . 1 0 ; <br /> __________________________________ —________---____________—_______ __ O <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. ....................................................................... ....... <br /> i <br /> i ) <br /> IN O <br /> O ...000tt1 �I <br /> O � \ <br /> T <br /> a <br /> o <br /> Z � <br /> P <br /> M <br /> d <br /> e ( <br /> V _ <br /> JJ <br /> to m m -0 <br /> c c <br /> o -rJ < o ° ° m <br /> T Nam - o• m n n x <br /> r = y > > �_ <br /> ON c O m ro <br /> O fA0 : D ' <br /> o a m <br /> m9 <br /> m <br /> .. .. ....re of O .. .... ........................................ ...................................... Q: > : O <br /> Sign ur or nt Date <br /> Remarks .......... .. ... .................................................................................................................................................. <br /> u <br /> ......................................................................................................... . ................. . ..... . F............... .............. .. <br /> [y ....... .. ... �: <br /> Inspection Date .�.- . ` ..." ' .. (/.J�...ll.U'A�..l..c.....1. ....... . . ... .. .• ............ .... �lm m o o g Rmi <br /> Zoning Ad nistratbr : <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 AP ROVED. <br />