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- <br /> Burnett County Office of Zoning Administratord o z <br /> 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < — <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use 1 c ?� <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> _/,`�u c. f�r�:D....... .......Gil...Ek................. . .... <br /> a <br /> d <br /> OWNER (please print) CONTRACTOR or SURVE R or AGENT n <br /> ...3...........I3c..X.:.............................................. <br /> .Al�.l.. t�.! ....... ............... <br /> ADDRESS ..................... t <br /> ADDRESS <br /> A']D�DpR.ESS . ............................................................................ ; <br /> ADDRESS <br /> PHONE ..................................................... .PHONE................................................................................ <br /> ........................................................................................... . . ..................................................................................... <br /> PLUMBER WELL DRILLER $II <br /> ..... . . ................................................................................ o �� �I <br /> ADDRESS . .......................................................................................... � •� <br /> ADDRESS � � <br /> n � <br /> .................... .... ..... ........................ ... <br /> ............................ .Y <br /> . . .. ... . ......................................................................... D.............. ' - <br /> PHONE PH....ONE " 'T <br /> Z <br /> DESCRIPTION <br /> y/ <br /> 4. Sanitary Facilities: o <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details <br /> New Building y No. Bedrooms .Gs <br /> „/�.. Type of Constructiopp: •••••••�•• �� 0 <br /> Addition ,,,,,, ,,,,,, �� „fj, /,..77/' ,,,••. Septic Tank Size Gals. ..... <br /> ..... <br /> Sanitary ;......... Size ...sz2...f... ft. x ...y.P.... ft. .......... <br /> Filling/Grading ,.... .... Height...fS.:...... Stories ............ 4a. Absorption Field Site: i <br /> Moving .......... Area ........................................... Soil Type .................................... ?— r <br /> t�' o <br /> Mobile Home ....... . Slope .......................... ............... i <br /> Privy ,,........ 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Well ,......... home,garage, motel, etc.) Dry Well ,......... w i <br /> Subdivision /}qC Seepage Trench <br /> Camping �� <br /> Unit Privy .., r <br /> Seepage Bed <br /> Location of proposed structures qnd 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 rs located at a highway inter y <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING f— <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. 1 t <br /> ______________________________________________________________ <br /> 5. Lot Size: �j Fig. A. 6. Location: o L �' <br /> ................ ft. x .............. ft. . ....U.:y'1...ati... <br /> ...... sq.ft <br /> . . ............................................................. <br /> N 0. <br /> O Q w <br /> y :4- <br /> O p <br /> V <br /> C <br /> O <br /> s <br /> ad 13 <br /> I, = � wmm� <br /> SRA n fl�Id m_ <br /> C <br /> N _. d m <br /> -O (P c <br /> _. m <br /> Z > <br /> 0 o o' <br /> o Vr o m 3 <br /> Q'0 <br /> N o <br /> 7 cL�dL� z <br /> Signature of Owner or Agent # >; Date <br /> .te��..... iso : : C <br /> X . . . <br /> Remarks ..................................................:. m m <br /> ........................................................................................................................................................................................ <br /> [I <br /> N. <br /> ......................................................................................................... .............. ................... ... : <br /> Inspection Date ........................ ><: — ro N m <br /> ............I......... 8 S 8 8 $ M <br /> ou, o <br /> Zoning Ad Inistrator g <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 riot 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 be made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br /> 1� <br />