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Burnett County Office of Zoning Administrator W 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3 <br /> o x°a <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as < H <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a �J/±�JJ <br /> j� [ ��/� d :lam <br /> c D <br /> ........................................ .................................................. ............................................................................................ <br /> OWNS (please print) CONTRACTOR or SURVEYOR or AGENT o. <br /> s, <br /> }r . .......................................................................................... m '� <br /> ....I.... ..+.i......................................... <br /> ADDRES ADDRESS <br /> ADDRESS ADDRESS <br /> ................................................. <br /> ............................................... ........................................... <br /> ........................................... <br /> PHONE '/ PHONE ' <br /> 1V2.�5.......... 9rPQ!'........................................ ............................................................................................ L R, <br /> PLUMBER WELL DRILLER \ ;.r <br /> I L Ap � ( <br /> AD E ADDRESS » o <br /> . . ... Sia � .............. <br /> O <br /> .... �....................................................... . ............................................................................ n <br /> PHONE PHONE Z r <br /> DESCRIPTION 4. Sanitary Facilities: A 0 0 0 <br /> 1. Work: 2. New Building Details No. Bathrooms .......... �� o <br /> No. Bedrooms M a i <br /> New Building ........•, Type of Construction: <br /> L.. <br /> Addition Septic Tank Size Gals. <br /> .......... .................................................... <br /> Sanitary 1 ,... Size .............. ft. x .............. ft. 4a. Absorption Field Site: <br /> Fillingl Grading ,,,....... Height............. Stories ............... ' <br /> SoilType .................................... <br /> Moving .......... Area .......................................... ��+ � ,o. <br /> Mobile Home .......... Slope ............ ........................ <br /> Perc. Rate ..... ........ %..✓t...... , <br /> Privy .......... 3. Use (describe exactly -family Dry Well <br /> Well home,garage, motel, etc.) """"'• ll ' <br /> .......... 9 9 Seepage Trench .......... PJ <br /> Subdivision .......... ...............................................I.... CYI <br /> Privy <br /> Camping Unit t �' n <br /> Seepage Bed :V' <br /> ------------------------------------------------------------ <br /> --- -- �� <br /> Location of proposed structures and 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 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 1 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> \,———— —__—__-- <br /> -------------------- ------------------ <br /> — <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... rJ <br /> V N <br /> N <br /> rC K <br /> N O <br /> o � <br /> \� O <br /> 1�I VV 1i1 0 <br /> m <br /> n: <br /> L; <br /> Z <br /> 0 <br /> :W d <br /> i ( � <br /> --, <br /> t� <br /> m i < a �. E <br /> m. rod <br /> C <br /> n < w m <br /> Z C, O n <br /> O n m 3 <br /> fA » <br /> o m <br /> D <br /> Signature of Owner or Agent Date X -M <br /> M <br /> Remarks ......................................................................................................................................................................... : : 0 <br /> ........................................................................................................................................................................................ it <br /> ....................................................................................................../.�./}........................................ ................................... H T <br /> im <br /> inspection Date ....................................... l�R r�lH..P.t? .../.... . .. . .. .tZ�........G..... `nE o oo ��` umi <br /> Q Zoning Admir �✓ 8 8 8' 0 8 <br /> A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> instruction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> tion before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build <br /> rmit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here <br /> i exist. Changes in plans or specifications shall not be made without approval of the Zoning Administrato,. <br /> 'TEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED.. <br />