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Burnett County Office of Zoning Administi ator <br /> APPLICATION FOR SANITARY — gig <br /> LAND USE — BUILDING PERMIT a 3. 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work describei I and 0 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements f the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the new end <br /> regulations of the State of Wisconsin. y <br /> OW <br /> ........ . ...................................................................... — g ER.....(Plea.. ....se. <br /> Print) ......................................................... S <br /> ...............:........... ....... <br /> CONTRACTOR or SURVEYOR or AGENT <br /> A RESS <br /> �6 J �% ST ADDRESS .......................................................... <br /> A.. ....................... .....................`.:..................................... <br /> DDRESS . ...............................................�•.....•.......................... . <br /> �fN ADDRESS <br /> .................. .... <br /> _ DO <br /> PHONE . .............................................................................. ....... <br /> PHONE <br /> PL��..........y................................................................. <br /> UMBER . ... ............ . ............................................................... . <br /> WELL DRILLER "" <br /> ADDADDRESS . .......R...ES........................................................................ <br /> S o � 1 <br /> P............. . . . . .................................................................. o iiiGVVVJSTTT <br /> HONE . ................................... . <br /> PHONE . ............................................. ....... C » ^ 1 <br /> DESCRIPTION <br /> 4. Sanitary Facilities: 0 0 <br /> 1. Work: 2. New Building Details No. Bathroomsnj <br /> „ ,,,,,,, <br /> New Building ,,,„�",• Ty f Conatructi n: No. Bedrooms <br /> ()OGZ� .. ....... <br /> Addition — Septic Tank Size Gals. i <br /> .... ... ... (t9....„.y <br /> Size .... ft.x....S.J......ft. <br /> Sanitary ; <br /> FIItInpfGrad[ng Height...... ....., Stories ...�.......... 4a. Absorption Field Site: <br /> i <br /> Moving .. . Area ....ilgG�.1V..".1.....G.�n. Soil Type ............................ . <br /> ...... .......... .. ... r i <br /> Mobile Nome .......... Slope .................................. .... o <br /> Privy 3. Use (cleyGEIbe exactly, 1 •family Perc. Rate ........................... . » <br /> ..... m _ <br /> Wall home,gara ,motel,etc.) Dry Well .• •••,,,, ,��, i <br /> .......... <br /> subdivision Seepage Trench ., ....... o <br /> .......... <br /> Camping Unit .. .. {,I:J=:................. — <br /> l;Jc—. Privy .. ...... � i <br /> ———————————————— ------ Seepage Bed <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched In Fig. A. :Z r <br /> Include road setback,side and backyard dimension and location and setback from all bodies of water. If property is local d at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersect on. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> ------------------ A” <br /> 5. Lot Size: �. 8 (� Fig. A. 6. Location: J '� E <br /> .............................. sq.ft. td,Lfd ..... <br /> .............. ....... fc� • .g) <br /> 0 <br /> 0 <br /> e o <br /> L%'vnI C P <br /> 0 -0d > mm -0 <br /> n wo < > > <br /> on S. S. M <br /> 006110 <br /> v..... ...... Z 1 <br /> Signature - - <br /> O A <br /> X A : m <br /> of Owner or Agent. ate e ' C <br /> Remarks '• g <br /> m a <br /> ............................................................................................... <br /> ................................................................. p <br /> ......................................... <br /> InspectionDate ....................................... <br /> N OD N <br /> Zoning Adminia ator g�L....... � g ' g <br /> NOTE: A preliminary site inspection must al made and site app vat granted on all structures involving sanitary fact[ties before constructio <br /> can began. D the case of sewerage disposal systems,a copy of the percolation test must be attached to this app[ic tion before a permit wtl <br /> be issued. is not purchase or install a septic tank, n any plumbing or start any building until a permit has been issued. A permit may be <br /> revoked if uta misrepresentation of ton of any of the information conveyed herewith is found to exist. Changes in plans or sp cifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPR VED. <br />