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Burnett County Office of Zoning Administrator V e <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 o <br /> + t. <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 ,J <br /> regulations of the State of Wisconsin. <br /> C a <br /> Sl..l. 1 iso x� . <br /> ... c�c .... r..a .................................... <br /> ......................... <br /> OWNER (pleas riot CONTRACTOR or SURVEYOR or AGENT <br /> LlJ ....... . .............................. 'a i <br /> ADDRESS <br /> All9 ESS � m Ul <br /> ............................................................... ... r4� .,...1L.... Q............ ' W <br /> ADDRESS ADDRESS <br /> ........... <br /> ........................................................................................... .P..H..ONE............................................................................ � <br /> PHONE <br /> .......... <br /> ........................................................................................... .................................................................................. <br /> PLUMBER WELL DRILLER <br /> ........................................................................................... ....AD....RES. E. S.S.............................................................................. <br /> ADDRESS Dm C) i <br /> n o —� <br /> ............. . . . .................................................................... . .' . ............................................................................... O .i <br /> PHONE PHO......NNEE <br /> 0 r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms v <br /> ...... 2. New Building Details ......•.•. 'o <br /> Now Building Type of Construction: No. Bedrooms .......... R �� <br /> Addition Septic Tank Size Gals. E : <br /> .......... .................................................... <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... i <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... Soil Type .................................... r <br /> ° <br /> Mobile Home .......... Slope .......................................... <br /> Privy .......... 3. Use Idescribe exactly,'I -family Perc. Rate ................................... <br /> Well Dry Well <br /> . .., home,garage, motel,etc.) ��•������� — <br /> Seepage Trench Z <br /> Subdivision .......... ° <br /> .. .. ... .................................................... <br /> Camping Unit .......... Privy .......... C C:n <br /> .................................................... <br /> Seepage Bed ......— W <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. _ Q <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. 4� SU j�: „<-, <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. �:' ;�: o <br /> — ---------------------------- i <br /> Cb.o P: � <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... VJ <br /> `"I,�,:W � <br /> A Rached csM o <br /> Pa <br /> 5 <br /> a -a3 <br /> 0 <br /> ° <br /> � T <br /> Z <br /> p <br /> a <br /> 3) Gln r- Dm W '9 <br /> 0 or >_ > 0 m <br /> n y <br /> 9 < d C y ° p 3 <br /> Z N < O m O <br /> ° o D 1 <br /> � m n <br /> , n : y <br /> O c m <br /> ........t'u"r' ............................................................. ...................................... <br /> x A m <br /> Signature of Owner or Agent Date <br /> Remarks ......................................................................................................................................................................... m _ <br /> n <br /> m •� <br /> N <br /> ...........................................................................................................................................�.../.J........................................ : o <br /> Inspection Date ....................................... .. ... . . ...... ....:f.'C.a!/7 .. ............ N O O N m <br /> Zoning Adminis a r 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 before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this application 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 or specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />