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t� <br /> Burnett County Office of Zoning Administrator Ln -oo `"o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT a 3. <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < N -^ <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m e� <br /> Ordinance Sanitation Code,and with all other applicable County Ordinances and the la and regulations of the State of Wisconsin. 3 o- <br /> y /� <br /> Se/ <br /> a <br /> k - f <br /> nix.f�1:.....f.�.......�.....N.�............................ <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT a <br /> : .:.. .R. u1�� .w.......................... . . . . . ................................................................................. a <br /> ADDRES� V0.2 <br /> �� ADDRESS <br /> a <br /> os ............", m 0...................... <br /> �a..-........... ......................................................................................... <br /> ADDRESS ADDRESS EO <br /> PHONE..�... .`..l• I5 ....................................... .PHONE................................................................................ .� <br /> . . ........ .... dw................................... . . . ..................................................................................... <br /> PLUMBER WELL DRILLER � � <br /> O <br /> .......... <br /> ........................................................................................... .AD.. D....... .................................................................... <br /> ADDRESS RES....S n o <br /> ........................................................................................... ... ..... ............................................................................... o' <br /> PHONE PHONE.. ... Z m i,4 <br /> DESCRIPTION 4. Sanitary Facilities: o ° o ° <br /> 1. Work: / No. Bathrooms .......... a i :T <br /> I/ 2. New Building Details o <br /> New Building Type of Construction: No. Bedrooms .......... <br /> Addition ,,,•„••„•, Septic Tank Size Gals. .......... M <br /> .......... .. A <br /> Sanitary .......... Size ......�..�.....ft. x ... .. . ft. .......... N <br /> Filling/Grading Height............. Stories ......�........ 4a. Absorption Field Site: a i <br /> Moving .......... Area Soil Type .................................... <br /> Mobile Home Slope .......................................... 1 0 <br /> .......... t i <br /> Privy .......... 3. Use (describe exactly, 1 -family Fare. Rate ................................... <br /> Well ......, home,gara e,motel, etc.) Dry Well <br /> ”"""" p '• <br /> Subdivision sent Seepage Trench .......... <br /> .......... .......... . .................................. <br /> Camping Unit „ , Privy .......... t <br /> .................................................... Seepage Bed <br /> ---------------------------------------------------------------------- <br /> Location of proposed structures and existing structures,well,sewage systems, roads etc., should he 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- <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. p' <br /> ----------------------------------------------------------- ---------- <br /> 5. Lot Si <br /> ��^ Fig. A. 6. Location: <br /> , 3.!4b ft. x ft. . ............................... sq. ft. <br /> N 00 <br /> O � <br /> e <br /> S o <br /> f <br /> N <br /> o :Z <br /> a <br /> m <br /> L-1 <br /> M N m -o N m Z <br /> �13y 0 7v Re .e 2 cfS7�^�S °sa�fl ” n v a m a F <br /> Swme setback mart„ e. � 5 : a <br /> Z D a <br /> /% 11119vr (�czrrm E� o <br /> 3J o <br /> — ERi C <br /> . atuire .... ....... ...... ./y�. ...... ...... ... ,�.... ate � o <br /> ignature of Owner or Agent Date <br /> X 71 <br /> Remarks ......................................................................................................................................................................... T m <br /> to <br /> .......................................................................................................... .. ............ .. ... ........................................... - <br /> Inspection Date ........... . ..................... . . ....... <br /> . I' 8 0 m istratorZoning Ad m <br /> 8 8 8 8 8 y <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary faciliti •s <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached o <br /> this application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any built - <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 tie made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />