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�'�7Y ) <br /> Burnett County Office of Zoning Administral or �' o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3• R <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described nd yt <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of he $ g3 <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws nd 3 <br /> regul tions of the Stateof Wisconsin. » o- <br /> /+ (�' di <br /> C.tJ.EJ�...K?.:.....A.I.J. ..................... ..�!�..... IIP(....SufJe�fi ?...{............................. . a* C). <br /> OWNER Ipl p 'nt1 CONTTCTOR or SURVEYOR Or AGHNT .. <br /> � e . . . r�.:...... ....mx....g.�. ................ ......................................... ..... <br /> ARESS r ADD ESS S �eT, 1/u-+-� `� ................... ..... <br /> O <br /> �.o.r n .,....1� ......53..)) O..................... ....Lt�eb......................... .., <br /> ADDRESS ADDRESS <br /> ........................................................................................... . . . . ............................................................................. ..... <br /> PHONE PHONE <br /> ........................................... ..... <br /> .. . ...... ............................................................................... . .EL. ..L...D. ..RILLE.. .... R...................... �\ <br /> PLUMBER W <br /> i icD <br /> O <br /> ADDRESS............................................................................ .ADDRESS................................................................... ... O <br /> 0 < <br /> ...... ..... <br /> ........................................................................................... ............................................................................... . O w <br /> PHONE PHONE Z N r <br /> DESCRIPTION 4. Sanitary Facilities: ° o <br /> 1. Work: 2. New Building Details No. Bathrooms ... ...... e <br /> No. Bedrooms <br /> New Buof Construction: "' """ E <br /> Septic Tank Size Gals. ... ...... <br /> Addition .......... .................................................... ; < - <br /> Sanitary .......... Size .............. ft. x .............. ft. ... ...... <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area Soil Type ............................. ...... i c i <br /> Mobile Home .......... $OPe ................................... ...... .. <br /> Privy 3. Use (describe exactly, -family Perc. Rate ............................ . .... <br /> .......... <br /> Well m <br /> Well .,,, home,garage,motel, etc.) Dry WeZ ; <br /> Subdivision t�-Ft4T Seepage Trench ... ...... c E <br /> ,X... .........................I.......................... <br /> Camping Unit Privy ... ...... <br /> .......... .................................................... <br /> Seepage Bed ... ...... p it-tZ� <br /> -------------------------------------------------------------------- -- <br /> Location of proposed structures and existing structures well sewage systems, roads, etc., should be sketched in Fi . A. I a ,`\ <br /> Include road setback,side and back yard 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. o <br /> __________________________________ -___________ <br /> 5. Lot Size: Fig. A. 6. Location: �,_ <br /> ................ ft. x .............. ft. . .................. q.ft. ...... <br /> civ N <br /> 0 <br /> a <br /> T <br /> Z <br /> O <br /> v <br /> 7 <br /> m = w m o =� cmc <br /> m a a m n n <br /> Z co <br /> Z y < N O r0 i0 <br /> O O � ! D ' <br /> 0 N a <br /> � o m <br /> » o . O <br /> � c <br /> n : m <br /> ........................................................................... ...................................... <br /> Signature of Owner or Agent Date <br /> Remarks a <br /> v <br /> O . 0 <br /> O ' O <br /> .................................................................................................... ^ N O <br /> N o N <br /> In <br /> Inspection Date ....................................... m <br /> Zoning <br /> Administrat 8 8 8 8 0 8 rn <br /> NOTE: A preliminary site inspection must be made and site appro I granted on all structures involving sanitary facilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this appl cation before a permit will <br /> be issued. Do not purchase or install a septic tank, do any plumbing or start any building until a permit has bee issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or 3pecifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />