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67-7 C41 . <br /> Burnett County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described nd 2p 2 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the i <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws nd <br /> regulations of the State of Wisconsin. <br /> a <br /> f L <br /> .............. ...... Mt � o ..................................................................................... ...... <br /> OWNER (Pi'apese print) I CONTRACTOR or SURVEYOR or AGENT C� <br /> ..................... ...... <br /> .. . ........... . .`....... 42 ..... . . . . ................................................. <br /> ADDRESS ADDRESSv 'Q <br /> a <br /> i \ <br /> i o <br /> ADDRESS ADDRESS <br /> ....... ...... <br /> ................................................................................ ... ..... <br /> PHONE PHO....NE i � V <br /> .. . ...... ............................................................................... . . . .. .......................... ........................................... ...... <br /> ..... , <br /> PLUMBER WELL..DRI LLER <br /> ...................................... . .................... ........... ........................................................................ ....... <br /> ...... .......................... <br /> p C <br /> ADDRESS ADDRES. S n o f� <br /> ^ <br /> ........................................................................................... .................................................................................... ....... _. <br /> PHONE PHONE Z <br /> DESCRIPTION 4. Sanitary Facilities: P S » <br /> 1. Work: 2. New Building Details No. Bathrooms .. ....... c <br /> New BuildingType of C <br /> ,,,,,,,,,, onstry7;1,.ition: No. Bedrooms <br /> AAddition .......... ................ Septic Tank Size Gals. .. ....... <br /> .......... <br /> sanitarySize .............. ft. x .............. ft. .. ....... <br /> "�.. 4a. Absorption Field Site: <br /> Filling/Grading .......... Height............. Stories ............... <br /> Moving .......... Area Soil Type ............................ ....... o <br /> MODIIs Home Slope .................................. ....... :� ^ <br /> .......... <br /> 71 <br /> Privy Perc. Rate ........................... ....... i <br /> .......... 3. Use (describe exact) 'i -fa ly 0 i <br /> Well .......... home,garage, motel, etc.) Dry Well .. ....... <br /> Subdivision <br /> Seepage Trench ....... Z <br /> .......... <br /> Camping Unit .......... .................................................... Privy .. .... _ <br /> Seepage Bed .. ..... <br /> ------------------------------------------------------------------- -- 1 N <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Ft 1. A. : L <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is local d at ;1L., <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersec ion. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. _ o <br /> -- — — ---- — ; <br /> — — --- ---------- - 9--------------------------- — `(n <br /> 5. Lot Size: Fig. A. 6. Location: <br /> i <br /> ....... ........ <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................... <br /> <,i <br /> R �.' <br /> o � � <br /> ^ C�o <br /> 7 ) <br /> `D 6 <br /> Z :Z <br /> d <br /> I �'1 <br /> 'tom M .N -o <nr Dmwy <br /> is64 c : d d c c <br /> n v < > > n <br /> O <br /> 0 <br /> o c o m <br /> x.1 ...... lja�nt / ............... �K <br /> Signature of Owner Date $ <br /> Remarks . ..... .. m <br /> ......................... %....�1/ ... / 1� �,......................................................................................... ..... o <br /> s : s <br /> J N m <br /> Inspection Date .... ...... ... . ...... ... ..... ......... . ........... .. ...9..... . . u u, N o o m <br /> Zonin mmistrator 8 8 8 8 8 8 y <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 app ication 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 ben 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 AF PROVED. <br />