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17 1 coro 'U i <br /> Burnett County Office of Zoning Administratord 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 :A <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as — :"111 <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 <br /> R (please print) L�� J CONTRACTOR or SURVEYOR or AGENT <br /> 97.x .f.............................................................. .......�c1Ac .....Gr11......s...- 3........................... a � <br /> AD�.ES .y ADDRESS v r�err . . . <br /> .. ............y ...................... . .......................................................................................... <br /> ADDRESS ADDRESS ��f <br /> ........................................................................................... <br /> PHONE . . . ..................................................................................... <br /> PHONE <br /> ........................................................................................... <br /> i� <br /> PLUMBER . ................................................................................ ......... <br /> WELL DRILLER <br /> ........................................................................................... <br /> ADDRESS . .......................................................................................... p <br /> ADDRESS m <br /> n 0 o <br /> . . .................................................................... .PHONE................................................................................ ?' <br /> PHONE <br /> DESCRIPTION 4. Sanitary Facilities: P o 0 <br /> 1. Work: 2. New Building Details No. Bathrooms .......... <br /> New BuildingNo. Bedrooms O <br /> �\ <br /> Type of Construction: ��••••••• <br /> Addition .......... .................................................... Septic Tank Size Gals. .......... < <br /> Sanitary Size ft. x ft. <br /> ......... .............. ..... ........ <br /> PIIIIngf Grading .......... Height............. Stories ............... 4a. Absorption Field Site: i <br /> Moving .......... Area ........................................... Soil Type .................................... r i <br /> Fi o <br /> Mobile Home .......... Slope ........................................ . o •• <br /> 3 <br /> Privy .......... 3. Use (describe exactly, 1 -family Pero. Rate ................................... a <br /> C i <br /> Well Dry Well <br /> home,garage, motel, etc.) <br /> Subdivision ,l/,. Seepage Trench .......... <br /> .................................................... •� <br /> Camping Unit .......... .................................................... Privy .......... <br /> Seepage Bed ' V <br /> .......... <br /> ---------- <br /> 01, <br /> Location of proposed structures and existing structures well, sewage systems, roads, etc.,should be sketched in Fig A. Include road C <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- 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. <br /> 0 0 <br /> -----------' — --------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. ............................................................................... o <br /> fs <br /> N 0 <br /> p. <br /> — 3 <br /> 1 � 0 <br /> f <br /> 0 <br /> yJ, <br /> 7J r e ur 03 2 <br /> n Q < �_ c m <br /> n — F <br /> o No <br /> vra „ a ao' E m <br /> Z O ii . D <br /> N, O <br /> :, m <br /> .............................................................. ................................. <br /> Signature of Owner or Agent Date ° <br /> X : 70 <br /> Remarks ......................................................................................................................................................................... T m <br /> ........................................................................................................................................................................................ — <br /> ....................................................................................................... ..................... p_ <br /> J"') fi U <br /> Inspection Date ................................... U' N 8 m 8 m <br /> P .... ...WRt '../........................... rn o rn o <br /> Zoning Adm�tl. kj 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 tie made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />