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ON COMPUTER/SCANNED l rryC,'I <br /> Burnett County Office of Zoning Administrator d 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 y <br /> 70 THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as -c - :VJ <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m <br /> Ordinance, Sanitation Code, and <br /> with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. fDa <br /> 1w'A .` ... . . �Y . ....... .................. ! .... ... au?. ................................... 3 O <br /> a <br /> H � <br /> OWNER?(plea a pri tN 1 CONTRACTOR or SURVEYOR or AGENT a �� <br /> .................................................... .Yr!.�G L ...i //.....sY�y:3........................I...... a <br /> ADDRESS ADDRESS <br /> ADDRESS ADDRESS <br /> ........................................................................................... <br /> PHONE ............................................................................................ <br /> PHONE <br /> ........................................................................................... . .......................................................................................... -\, <br /> PLUMBER WELL DRILLER <br /> ........................................................................................... � <br /> ADDRESS . .......................................................................................... m C) \ <br /> ADDRESS <br /> n o <br /> ........................................................................................... HE............ .. <br /> PHONEPON . ................................................................. 0'N ,. <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> 1. Work: 2. New Building Details No. Bathrooms <br /> .......... <br /> New BuildingNo. Bedrooms o <br /> .......... Type of Construction: <br /> • • •••• ice, <br /> Addition ,,,,,,,,,, Septic Tank Size Gals. .......... <br /> ....................... <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... <br /> Filling/Grading ,,.,,,,,,, Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... Soil Type .................................... r i <br /> Mobile Home .......... Slope .......................................... <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> well , „-„ „ home,garage, motel, etc.) Dry Well .......... i i <br /> Subdivision ., Seepage Trench .......... <br /> Camping Unit .................................................... Privy .......... <br /> .......... .................................................... <br /> Seepage Bed .......... <br /> -- ------------- rn <br /> Location of proposed structures and existing structures well,sewage systems, roads,etc., should be sketched in Fig. A. Include road � <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> ______________________________ o' <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. - ............................... sq. ft. ............................................................................... <br /> i- 333 c + r o <br /> - o <br /> r � <br /> : <br /> 0-' <br /> N m z <br /> C c N <br /> E <br /> m <br /> c '9 <br /> am <br /> Z a z <br /> IN CD <br /> .................................................... <br /> . ... ...................................... o C <br /> Signature of Owner or Agent Date <br /> X : : : z <br /> Remarks ......................................................................................................................................................................... m m <br /> m <br /> ........................................................................................................................................................................................ -- <br /> ........................................................................................................ . n <br /> 'fit <br /> : -N - m <br /> Inspection Date ....:.................................. E �E�t N N + 8 <br /> .... ......... ..... u � o � Nm <br /> ..... <br /> ................. <br /> Zoning Ad nistrator ! 8 8 8 8 S 8 n <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <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 or specifications shall not We made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />