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Burnett County Office of Zoning Administrator 'g3� <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 9. ; U <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and12 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the o c <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> regulaion s of the Stat fWisconsin. m <br /> roc ....... ................................ .....W <br /> �I ne .. ( <br /> OWNER (plea" rint) CONTRACTOR oURVAYl t' or A <br /> .. POUIC. h ) ...................... .... a <br /> NT <br /> c...................... ...... g - <br /> AD SS ADDRESS m <br /> LIP(.t.... .... ..:..... 1... .. ..... .fit .. ................... ...... <br /> ADDR SS ADDRESS \ r <br /> ........................................................................................... . . . ............................................................................ ...... <br /> PHONE PHONE <br /> ........................................................................................... . . .............................................................................. ...... <br /> PLUMBER WELL DRILLER :•`�, <br /> O <br /> ADDRESS ADDRESS » G <br /> _. < <br /> PHONE.... . . .................................................................... .PHONE........................................................................ ....... 'Z « ,» <br /> r <br /> DESCRIPTION 4. Sanitary Facilities: ° c ° <br /> No. Bathrooms 0 <br /> 1. Work: 2. New Building Details .. "••••. o ' <br /> New Building .....•.... Type of Construction: No. Bedrooms .. ....... ; <br /> Septic Tank Size Gals. <br /> Addition .. ....... <br /> Sanitary .......... Size .............. ft. x .............. ft. <br /> .. ....... <br /> FillinglGreding .......... Height........... Stories ............... 4a. Absorption Field Site: <br /> Soil Type ............................ ....... r i <br /> Moving Area ........................................... o <br /> Mobile Home .......... Slope .................................. ....... » <br /> .......... <br /> Privy .......... 3. Use (describe exactly,'1 -family Perc. Rate ........................... ....... <br /> Well .. home,garage,motel, etc.) Dry Well .. .......Subdi <br /> Seepage Trench Z <br /> Camping <br /> - <br /> .. .. ... .................................................... Privy <br /> i <br /> g <br /> CamDing Unit .......... <br /> .................................................... Seepage Bed <br /> ____ ___ __-----____ _____________ ____------- -- N <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fi 1. A. _ <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is Iota ed at _ <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersec ion. `— <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. 0 <br /> -------------------------------------------------- ___----__ -- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq. ft. ...................................................................... ........ <br /> i <br /> i <br /> 0 <br /> J <br /> �o ► e I I Pd a �3 <br /> » 0 <br /> 0 ° <br /> J <br /> I <br /> m <br /> N <br /> Z <br /> O <br /> ,n <br /> d <br /> J <br /> u] <br /> Nrr <br /> n1 = M. N N o m a <br /> m Na�< -� am nay <br /> ON < N O > <br /> a i <br /> 2�0 a : <br /> o �J N n � <br /> o c <br /> m <br /> ° Jo . O <br /> n : m <br /> ........................................................................... ...................................... > O <br /> Signature of Owner or Agent Date o <br /> 0 <br /> N <br /> Remarks m a <br /> N <br /> ................................................................................................................................................................................. ...... <br /> o : g <br /> ...................................................................................................... .. ....................... .. .... r <br /> n ..... N N N N m <br /> Inspection Date ....................................... .�!,.L�A.1... ...r..... .4 (...1.u� .. .... . o cn �n o 0 o m <br /> Zoning Administr o $ S S o o W <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary f acilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this apr lication 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 o specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE ANDA PROVED. <br />