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d«� <br /> Burnett County Office of Zoning Administrator o <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 p <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the ,$ c <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the State of Wisconsin. <br /> ...... ... .EP.G. oR7 ................................ ............................................................................................ <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT <br /> f. ....! :ffi...::.............................I............ ............................................................................................ <br /> ADDRESS ADDRESS m <br /> ADDRESS ADDRESS <br /> .................................................................................. ............................................................................................ <br /> �1 <br /> PHONE PHONE <br /> .. . . . . 4 fJ...... t?. Y1.:j........................... ............................................................................................ <br /> PLUMBER WELL DRILLER <br /> .. . . . ..... ...................... . . . . ................................................................................... o <br /> ADDRESS ADDRESS » C <br /> ......................... r <br /> �.............................. . ................................................. ....................................... <br /> PHONE PHONE Z <br /> DESCRIPTION 4. Sanitary. <br /> Facilities: i ° 0 ° �1N' <br /> 1. Work: 2. New Building Details No. Bathrooms ..a.. iV <br /> New Building .. Type of Construction: No. Bedrooms <br /> .... <br /> Addition ........... . . .e. „i5a:............... Septic Tank Size Gals. J-?? <br /> Sanitary ...x... Size ....a2. .. ft. x ..;$') . ft. . <br /> Filling/Grading Height.. St ries ....1. 4a. Absorption Field Site: <br /> .......... X07 ......... <br /> Moving AreaE?.6 Soil Type .................. 1.1- .... r i <br /> Mobile Home Slope ..........................�. ll•SS:J ^ <br /> Perc. Rate .......................familPrivy .......... 3. Use�ldescribeexactly,� ... ..... m <br /> Ftp <br /> Dry Well m '• `� <br /> Well .......... home garage,motel, etc.), """"" — <br /> Subdivision Seepage Trench .......... o <br /> .......... .......... 1U. 7 ..�L`J.lh/.4r....... <br /> Privy .......... OJ . <br /> Campingunit .......... .............. ..................................... Seepage Bed <br /> ---- <br /> Location of proposed structures and existing structures well sewage systems, roads, etc. should be sketched in Fig. A. _ : n c <br /> Include road setback,side and backyard dimension and location and setback from all bodies of water. If property is located at ;� A� <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. 'fit :` <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. :� �' 0 V <br /> ______________________________________________________________________ . <br /> y <br /> 5. Lot Size: �dJ Fig. A. 6. Location: <br /> .I..I.. ... ft. x ..7.P.Q.. ft. — ............................... sq.ft. ............... ..... .... /.....��.................................. <br /> rrnn �D <br /> ti n <br /> IN <br /> 0 p <br /> o � � <br /> O <br /> �l <br /> f <br /> z <br /> o <br /> I :d <br /> n �c o o —. —. m <br /> O t0 m <br /> Z O <br /> o D <br /> � �� U) A <br /> OO o m <br /> o - <br /> Fi�rVtureof Ownn/er or Agent <br /> Agent Date <br /> Remarks ... .1. .:x:4: <br /> . <br /> ' <br /> ................. ................................................................................................................................. <br /> ........................................................................................................................................................................................ Ro : c <br /> '' nn o <br /> ........................................................................................................... ..................... V` <br /> Inspection Date ..L�.-.:5.......?.1............. P... dRL.. .. .. $ <br /> .... <br /> Zoning AdminI r for 0) $ <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 />