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Burnett County Office of Zoning Administrator 9' o / -- 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT3. \ <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 <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a a <br /> O\�NER (please print) .y CONTRACTOR or SURVEYOR or AGENT m <br /> ... uJ Syoa ...... . ............................................................................... d <br /> ..�............ .. . .Y.. <br /> ADDRESS C` <br /> .................................................................. ........................ .A...... . . .RESS.............................................................................. V\�� <br /> ADDRESS DD <br /> ........................................................................................... . ....................................................................................... <br /> PHONE PHON.... E i� <br /> ........................................................................................... ............................................................................................ <br /> PLUMBER WELL DRILLER i <br /> ......... . ........................................................................—.... .ADDRESS D—D- . . ...................................................................1,.......... <br /> ADDRESS <br /> 0 o <br /> PHONE PHONE n <br /> DESCRIPTION 4. Sanitary Facilities: °or <br /> 1. Work: 2. New Building Details No. Bathrooms <br /> New Building No. Bedrooms o ' <br /> Type of Construction: p, <br /> Addition .......... .................................................... Septic Tank Size Gals. .......... <br /> Sanitary Size ft. x .............. ft. •..•• •••• ' ' '• <br /> Filling/Grading ,,,,,,,,,, Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... AreaSoil Type .................................... `: r i <br /> ........................................... <br /> Mobile Home .......... SIOpe .......................................... o, w <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... 3 <br /> Well .......... home,garage, motel, etc.) Dry Well y iW\ <br /> Subdivision Seepage Trench ........., <br /> .................................................... <br /> Camping Unit ,,,,,,,,,, Privy \ <br /> .......... <br /> .................................................... <br /> Seepage Bed .......... <br /> to <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road t 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 <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING C 5 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS.---------------------------------------------------------------------- <br /> r <br /> 0 0 <br /> 5. Lot Size: Fig. A. 6. Location: <br /> . . . . ........ ft. x .............. ft. — ............................... sq.ft. ............... <br /> � � � /J ' C� <br /> N \ 0 <br /> lrr o <br /> v <br /> )l a <br /> Z <br /> 0 <br /> m <br /> m <br /> fA <br /> )< 9 on d a c <br /> � mm <br /> Z eo D _.n <br /> o �o nm 3 <br /> ..igna.ture of Owner or Agent.................................................................. ................Date �o c <br /> Signa <br /> X z <br /> Remarks ......................................................................................................................................................................... ij <br /> : m <br /> m <br /> t» <br /> ........................................................................................................ <br /> .. . . . ..... ...... ...... ........... <br /> 9:0 T <br /> Inspection Date .......................4............... .JJ.%!�'.. ...:. ....f. .. . . . ... >'`� o Jr '0 8 0' m <br /> Zoning Admi Istrator t,j 8 $ 8 $ $ $ cn <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 not 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 lie made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />