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Burnett County Office of Zoning Administrator 3 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3. <br /> - ° w <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as N <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use mt <br /> Ordinance, Sanitation Code, and with all other applicable County ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> E .. .. - Z ../V ......1 .Lc....Y...&. ............................................ <br /> ...��d. �.T......................... r ................. / <br /> OWNE (please mt) CONTRACTOR or SURVEYOR or AGENT o. <br /> '/..�.�.' � .......s.°........ .... x f..., ��1 .,... .............. d �! <br /> ADD,R� S ADDRESS <br /> ...................... <br /> ?9l��� ../•vl'• . 1•/../ ., ` ` v`................................................................ <br /> ao�`"sL ...... Y '. <br /> ADDRESS <br /> /�� .... '.. .-....� <br /> PH ..................... <br /> ONE PHONE <br /> . ....................... . . .. ... . . . . .. . .. . � <br /> ................................................................................... . ..... ..... ..... .... ....... .. .. . ........ ... ...... . <br /> ........ WELL DRILLER ' <br /> PLUMBER : •� <br /> . .............. ................................................................ m <br /> ................................................................................... ............ <br /> ........ ADDRESS <br /> ADDRESS n O <br /> . ... ............................................................................................ <br /> o' <br /> .. ............ <br /> .................................................................. .. PHONE <br /> PHONE <br /> DESCRIPTION 4. Sanitary Facilities: <br /> v <br /> No. Bathrooms o <br /> 1. Work: 2. New Building Details No. Bedrooms <br /> New BuildingType of Construction: <br /> •' Septic Tank Size Gals. <br /> Addition <br /> /:a. <br /> .......... '• <br /> Sanitary .......... Size .Q (0.... ft. x ...lJ. .. ft. 4a. Absorption Field Site: <br /> FillinglGrading Height............. Stories ............... ! E <br /> Soil Type .................................... K. r i <br /> Moving Area <br /> ..... Slope .......................................... o ' <br /> � <br /> Mobile Home .....I.... Pere. Rate ................................... <br /> Privy 3. Use (describe exactly, 1 -family Dry Well • • K,. <br /> Wellho are e, motel,tt .) / <br /> /,B ,[j 4' Seepage Trench .......... <br /> Subdivision .......... .../.••ri.."r••. .................... Privy <br /> v <br /> Camping Unit .......... ........................................ .......... <br /> Seepage Bed /� <br /> ...... — Cn (A <br /> ------------------------------- ,� N <br /> _______________________________________ c <br /> Location of proposed structures and existing structures,well,sewage systems, roads, etc., should be sketched in Fig. A. Include road a <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- rl�' <. <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING �� a <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. p <br /> ---------------- ' G <br /> ---------------------------------------------- 1 <br /> 5. Lot Size: Fig. A. 6. Location: rs a f1 (Y1 <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... ... <br /> m <br /> N O <br /> L ' <br /> O <br /> l O tj J <br /> I <br /> T <br /> _ m <br /> W 0 <br /> I� 'JmUs r� <br /> O���j,L r✓ G` <br /> gerNm <br /> O; N m <br /> 1 C (Il G c: .G ro C m <br /> a � <br /> og <br /> O O n b 3 <br /> (A <br /> At nr j <br /> 't . <br /> m <br /> _ p <br /> o C <br /> Sig§traof Owner or Agent Date X m <br /> m <br /> Remarks .................................................................... .� : : :: p <br /> . ........................................................................... n : <br /> .......................................................................................................... .. <br /> . ............................. .................................. T <br /> ....................................................................................................... <br /> O fT O' N ' m J <br /> /y fT O .� <br /> Inspection Date ....................................... ..?>.�-X0. . ..1. ............. ......:J..�.�............... <br /> Zoning Adm nistratori 8 8 8 8 8 <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facllitics <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 it misrepresentation of any of the information conveyed hcri:- <br /> with is found to exist. Changes in plans or specifications shall not be made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />