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"i1 i'(h�ljlr> , <br /> Burnett County Office of Zoning Administrator 00 T o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3' o <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 m [� <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations o the State of Wisconsin. 3 a [� l_h\ <br /> Glen Johnson <br /> � �..ltl .:.. �11? ..L�2t.. .....c r�.. . . . . ..�017 .�.......z .7. :..l.�G?..'........... A a <br /> 0 <br /> �[1 f <br /> OWNER (please print) �1 CONTRACTOR or SURVEYOR or AGENT a <br /> C <br /> Grantsburg, WI 54840a < <br /> ............................................................................ .AD.. D..........RES.S.............................................................................. z <br /> ADDRESS '� <br /> . ............................................................................ .......DRESS..................................................................................... <br /> W :� <br /> ADDRESS AD <br /> 715-463-5660 �, iso io <br /> ............ <br /> .......... <br /> ............................................................ ....................................................................... <br /> PHONE��••�•• •• PHONE <br /> Donald Daniels :0 <br /> ......................................................................... . ......................................................................................... <br /> PLUMBER W..ELL DRILLER � <br /> Box..W..............Siren.t.....!...?..... 2 <br /> 5487 .................... <br /> 72 <br /> ADDRESS ADDRESS o <br /> ....................................................... 0' ` <br /> PHONE PHONE Z o r <br /> DESCRIPTION 4. Sanitary Facilities: ° <br /> 1. Work: 2. New Building Details No. Bathrooms ......1... :q0 0 <br /> New Building No. Bedrooms a i <br /> Type of Construction: <br /> ......... 100 ... <br /> Addition ,,,,,,,,,, .................................................... Septic Tank Size Gals. .. < <br /> Sanitary ...X.... Size .............. ft. x ft. " """' ' <br /> PillinglGrading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... Soil Type .................................... r i <br /> o <br /> Mobile Home .......... Slope .................................I........ 5 .. <br /> Privy .......... 3. Use (describe exactly, 1 -family Pere. Rate .......................3...•.••••. I <br /> Well .......... home,garage, motel, etc.) y <br /> Dr Well .......... o S3 <br /> Trench .......... <br /> Subdivision .......... Seepage ' <br /> .................................................... <br /> Camping unit single..family...homePrivy ................... Seepage Bed 8x47 ingr.d_...press. ?* <br /> ---------------------------------------------------------------------- <br /> N <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be sketched in Fig. A. Include road Q <br /> setback, side and back yard dimension and location and setback from all bodies of water_ If property Is located at a highway inter- o, <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING vl <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... <br /> m <br /> ra <br /> 1 C <br /> Y 0 n <br /> c N <br /> o w <br /> vl <br /> rvl � <br /> � o <br /> 10 <br /> See State approved plan i T <br /> (/J z <br /> o <br /> d <br /> C> <br /> r 9 w m <br /> C N m O <br /> a U < N <br /> m <br /> Z o 0 0 <br /> 0 o am <br /> o : m <br /> Signature of Owner or Agent ' Date <br /> x <br /> m <br /> Remarks ......................................................................................................................................................................... m0 <br /> m <br /> ....................................................................................................... .... ................... . ................................................. Ut? . : : : <br /> Inspection Date ....................................... z m <br /> ... ........ 9... ...................................... <br /> oa oP'n oa m <br /> Zonm ministrator 8 8 8 8 8 8 N <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 Adm inistratof . <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />