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Burnett County Office of Zoning Administrator �' c <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3• <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and nry �1 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the n <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 �J <br /> regulations of the State of Wisc in. » " <br /> .........J(..�1..:.. :..i... d..M..A..L...................................... .../..<.��:�'.L..`�Q.�U..S.1..� KL.b,..�..�..Q..�Y............. n 42i OWNER )please print) CONTRACTOR or SURVEYOR or AGENT <br /> ........s ., .S ..... ... .bTt'd ..o�.t.Q.. o...... <br /> ADDRESS AD ESS, <br /> ............... .... �../...12. .N..,....�cL�::.., .z. ................. , <br /> ADDRESS ADDRESS , / <br /> '.........7/..�i.'..r�a "..7+'.1.. ...................................... ........ 1/.. 5.....��.c� ` .":. ` /............................. <br /> PHONE ...................................... PHONE <br /> .......................................... . ............................................................................................ (/ <br /> PLUMBERWELL DRILLER <br /> 3ss .... . .. . .. . .. <br /> ........................... ............................................... <br /> ADDRESS �Il� v ADDRESS O .Ll <br /> n o <br /> ........... <br /> ........................................................................................... . .. .......................................... ............................ <br /> PHONE P..HO..N..E Z N r I <br /> DESCRIPTION 4. SanitaryFacilities: o <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details .......... p <br /> New Building No. Bedrooms <br /> ,,,,,, ,., Type of Construction: .......... <br /> Addition .................................................... Septic Tank Size Gals. .......... <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... i <br /> Fillingl Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Soil Type .................. 'r- <br /> .......... <br /> Area ........................................... .... . ...... <br /> MODIIa Home $OPe ............................ ........ o <br /> .. <br /> Privy .......... 3. Use (describe exactly,*1 -family Perc. Rate ................................... 2�' <br /> Well ,We,garage, n�pUelietc.) Dry Well .......... � <br /> �_ Seepage Trench r-` <br /> ......... m <br /> Subdivision J" o <br /> .......... .... <br /> Camping Unit Privy .......... <br /> Seepage Bed .......... <br /> t <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. Uj <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. i o <br /> ___ Q J <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ��' <br /> ................ ft. x .............. ft. — sq.ft. i <br /> ............................... ............................................................................... <br /> j <br /> ii <br /> N <br /> o 0 � <br /> o <br /> € Z <br /> Z <br /> O <br /> a <br /> d <br /> J <br /> M <br /> M <br /> M c � w m n cm cm <br /> neo < J J n - - m <br /> m Nn�c am an 9 <br /> (_ y J J 3 <br /> Zoo : -2 D� -1 <br /> m <br /> On <br /> o mo : m <br /> � J . O <br /> _ � c <br /> A Y- <br /> rl✓... . ........ .. . . ..................... ...... .............. . g . <br /> m <br /> Signature of O er or Age .n Date <br /> T : m <br /> Remarks ......................................................................................................................................................................... m _ <br /> H <br /> u <br /> o : g <br /> ...................................................................................................... ........ ................ ......................................... <br /> 6� .................... ° N No � m <br /> Inspection Date ....................................... .;� ..:-.. :;lF'{'r` ............... 41 `� m <br /> Zonin ministrator o $ g g rA <br /> NOTE: A preliminary site inspection must be made an site approval granted on all structures involving sanitary facilities b onstruction <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 />