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Burnett County Office of Zoning Administrator o 0 <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 located as — <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m c Sil <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 a <br /> ........................... ...:or A'6' .................................... :� f <br /> OWNER (Please print) CO{TRACTOR or SURVE�or AGENT <br /> .1. ....0...................................................................... a :� <br /> ADDRESS ADDRESS iC <br /> �t <br /> ��.... . .... ..%....sy.�y,3 <br /> ..... ... . ............................................................................... ................................... <br /> ADDRESS <br /> ADDRESSC <br /> ............ <br /> ........................................................................................... ................................................................ <br /> ................ ti. \ <br /> PHONE PHONE �\ <br /> :ti s <br /> ........................................................................................... WEL. . . ..L...DR...I'LT'T''E' ..................................................................... <br /> PLUMBER -\ ?� <br /> 0 <br /> ADDRESS ADDRESS n o <br /> p r. <br /> .......................... <br /> .PHONE........................................................................................... Z <br /> PHONE 0 <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms <br /> 2. New Building Details """"" o - <br /> Naw Building .......... Type of Construction: No. Bedrooms .......... i 'o <br /> Addition .................................................... Septic Tank Size Gals. .......... •� i i <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... <br /> Filling)Grading ......•... Height............. Stories ............... 4a. Absorption Field Site: i <br /> Moving .......... Area Soil Type ................. <br /> ........................................... ................... <br /> Mobile Home o i <br /> Slope .......................................... <br /> .......... <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate .....4............................. <br /> Well „ Dry Well ..........•,,,,,., home,garage, motel, etc.) Seepage Trench <br /> SubdivisionLl... .................................................... Privy <br /> Camping Unit <br /> Seepage Bed .......... <br /> ----------------------------- N <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 water. If property is located at a highway inter <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING H <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o� <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. fftt. —/............/..y...�............ sq. ft. ............................................................................... <br /> .336337 Lam ! � o <br /> � f <br /> E <br /> p <br /> pte - See- m,N�fes o� De, 3.r�, 148s mee Fi a . <br /> qq <br /> CoNGI[frarv, S 1-3 , L f) [ m <br /> ' ied actbe <br /> T :EWM <br /> n tp rr ia� = 2. nF <br /> m an �- C m m <br /> Ov_,. m Dn m <br /> 2 0 p <br /> i� o <br /> o <br /> ........... �= p <br /> Signature of Owner or Agent Date <br /> X <br /> Remarks ......................................................................................................................................................................... m <br /> v <br /> ........................................................................................4.........v,i.... ............� ............. . . . . . . T <br /> a:P . . - 8 <br /> Inspection Date ....................................... w U o o u, o f' m <br /> .................... <br /> ... ... .......9............. .... .�fl'...—......... . o . <br /> Zonin Adminis for 8 8 8 0 8 8 W <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 Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br /> 31(, ,., CJJ - 7 11,5--4 <br />