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Burnett County Office of Zoning Administratord 0 1 Z <br /> APPLICATION FOR S NI�TARY — LAND USE — BUILDING PERMIT 3. <br /> TO THE ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as i <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m dpp <br /> Ordinance, <br /> Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a >� <br /> lv..C.1. .r. .: ..5..... ./.. 1�F .un.IJ... ............................................................................................ <br /> OWNER (pie se pri� / CONTRACTOR or SURVEYOR or AGENT m m <br /> S Y� <br /> ......I..1...1..'.�............I..... .:..... ............................................................................................ <br /> AD RESS ADDRESS ?� 11 <br /> ........................................................................................... /7!\.. <br /> ADDRESS .ADD.... ...R...ES................................................................................ CQ I <br /> S :! <br /> PHONE . ............................................................... <br /> ON ........................... <br /> PHONE <br /> i r <br /> PU BER / WELL DRILLER :OC <br /> .... -.. v.. .. .... FV..f.S.A..t:1�............................... ............................................................ <br /> f .. <br /> ADDRESS) —� ADDRESS ............................. <br /> .. �...�d..`S.! L.�.Ij......ti.?. ?✓.f.?r.?�IIP..k.....< ..I:........ ..HON.................................................................................... ?' <br /> PHONE :i ' 1 c[ 9�! Z :\ <br /> DESCRIPTION 0 '\ <br /> 4. Sanitary Facilities: ° o ° t� <br /> 1. Work: 2. New Building Details No. Bathrooms .....�... <br /> 0 <br /> New Building .......... Type of Construction: No. Bedrooms :� a <br /> Addition .......... .................................................... Septic Tank Size Gals. <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... 'Oo i <br /> FillingiGrading4a. Absorption Field Site: ip i <br /> ,,,,,,,,,, Height............. Stories ............... <br /> Moving .......... Area ....................... Soil Type ...................f................. <br /> .................... <br /> Mobile Home Slope r <br /> o <br /> .......... <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ............/..................... <br /> Dry Well "<> <br /> Well .......... home,garage, motel, etc.) "' <br /> SubdivisionSeepage Trench �-' <br /> Camping Unit .......... Privy J E <br /> Seepage Bed .. -- <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road <br /> setback, side and back yard dimension and location and setback from all bodies of waterproperty Is located at a highway inter <br /> . If �_ <br /> or <br /> section, show the Intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING < <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. P <br /> -------------------------------------------- ------------------------ <br /> 5. Lot Size: Fig. A. 6. Location: : <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... f <br /> P <br /> N <br /> A <br /> N O <br /> o <br /> O <br /> a : o <br /> s <br /> T r.1 <br /> Z <br /> O <br /> J <br /> U1 <br /> N <br /> N r no :E m m Z <br /> -O V1 < yC : .G ro c <br /> Z o o a a m <br /> o aro 3 <br /> EA – <br /> v €W o <br /> 0 <br /> 0 <br /> Signature ofOw e'r or Agent / Date : : <br /> ... . .. . . . .. X M <br /> Remarks .. /... .............................................................................................................................................. mm <br /> v <br /> ....................................................................... <br /> r�cYir... ...... ............................ <br /> : : <br /> � II <br /> Inspection Date .... ' ................................. ' ro m v m <br /> . . ....... .. ......... ............ � o; ornomomm <br /> Zoning Ad nistrator ? $ $ $ $ $ in <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 be made without approval of the Zoning Aclm inistrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />