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( / p <br /> Burnett C6unty Office of Zoning Administrator ' <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and q <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the 4 `� <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws <br /> reg'ulat onsof the Stateof Wisconsin. q _ m <br /> ....1(.11saq le..�:...�Lt�: o...�� �Yh....... _ <br /> .� ......... ..... <br /> OWNER Ip eue rin CONTRAC R or SURVEYOR or AGENT <br /> .. �. ..)...�. <br /> ADDRESS A ESS �l <br /> I <br /> F. . .m �.1....i �+ �......: 1.' . ................ ...... .�:re�..,...V�L .....� ................... .................... ...... <br /> ADDR •' ADDRESS <br /> . ..... ............................................................................ ...... . <br /> ........................................................................................... PHONE <br /> PHONE '-� <br /> . ...................E..R.................... ......................................... ....... <br /> ........................................................................................... WE LL DRILL <br /> PLUMBER ' <br /> . .................................................................................. ....... <br /> ADDRESS ADDRESS M p <br /> . ... . . . . . ...................................................... . .................................................................................. ....... <br /> PHONE PHONE C o <br /> DESCRIPTION o <br /> 4. Sanitary Facilities: a <br /> 1. Work: 2. New Building Details No. Bathrooms . ...... c <br /> New Building .......... Type of Construction: <br /> No. Bedrooms • ...•.•. <br /> Septic Tank Size Gals. . ........ <br /> Addition .......... .................................................... <br /> Sanitary .......... Size .............. ft. x .............. ft. i <br /> Filling/Grading <br /> .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Soil Type ........................... ........ i r i <br /> Moving Slope .............................. <br /> Area o <br /> Mobile Home .......... ... ........ .. <br /> Privy 3. Use (describe exactly, 1 -family <br /> Perc. Rate .......................... ........ m <br /> . home,garage,motel, etc.) Dry Well •• Z Well ' <br /> Seepage Trench . ...•.•.. o <br /> Subdivision .. . .................................................... Privy ..... <br /> Camping Unit .......... ..........................I......................... Seepage Bed <br /> ----------------------------------------------- - <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in F g. A. g <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is loc ed at < <br /> - <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the interse tion. „ <br /> STRUCTURES AND ADDITIONS. o <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED ST __— <br /> ------ -" <br /> 5. Lot Size: Fig. A. 6. Location <br /> ................ ft. x .............. ft. — ............................... sq.ft. ..................................................................... ......... <br /> i <br /> I ° o <br /> 7R E <br /> /1 T <br /> Z <br /> 2 <br /> 0 <br /> p <br /> M co M. m ori n cC cm m <br /> OTNam ''- nm a <br /> O < d <br /> CO J 5 ; <br /> Co. •f N O 10 (O <br /> O O Q ' <br /> �8 o m <br /> a O <br /> � � C <br /> x n : m <br /> ............................................................. ...................................... o <br /> Signature of Owner or Agent Date <br /> A ' <br /> O ; <br /> Remarks <br /> ............................................................................................................... <br /> ............................................. ........ <br /> ........................................... ..... .................. .. ............ .. <br /> N T <br /> U V O O N m <br /> Inspection Date ....................................... <.... . o:7I4 ionilri'g ... .. mist!(.. ..Y . 8 8 8 8 8 8 to <br /> Zoning Administrztgr � <br /> NOTE: A preliminary site inspection must be made and site app vol 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 a plication 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 %PPROVED. <br />