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Burnett County Office of Zoning Administrator L / --I 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 <br /> Ordinance, Sanitation Code, and Tito all other applicable County Ord i nces and the laws and regulations of the State of Wisconsin. 3 C. i oU\ <br /> . . . .. ... ............................ ° <br /> ;W4R pe rint. �� C TR OR or S VEYOR or AGENT a <br /> ............ ...[.r . ....................................•••••................. '••.... ......................................................................(J.Z' 7D <br /> ..... a <br /> ADDRESS AD ESS <br /> ..... . . ................................................................................. /, '� �� 7�. <br /> ADDRESS A�ESS . ..Z...Irl/................ ......................................... till <br /> . . . . .................................................................................... \ <br /> PHONE. ............................................................................... PHONE <br /> ............................................................................................ : "\ <br /> PLUMBER WELL DRILLER <br /> . .. ............................................................................... . ................................................................................ v <br /> ADDRESS ADDRESS n G7� <br /> o �. <br /> ........................................................................................... ............................................................................................ <br /> PHONE PHONE J <br /> N <br /> DESCRIPTION 4. Sanitary Facilities: <br /> 1. Work: 2. New Building Details No. Bathrooms .......... <br /> New BuildingType of Construction: No. Bedrooms .......... <br /> Addition ... ...... .................................................... Septic Tank Size Gals. .......... <br /> Sanitary .......... Size .............. ft. x .............. ft. .......... <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... Soil Type .................................... ? r <br /> Mobile Home Slope .......................................... .» <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... <br /> Well home,garage, motel, etc.) Dry Well .......... i <br /> Subdivision ✓ Seepage Trench .......... <br /> Camping Unit .................................................... Privy I......... <br /> .......... ......................I............................. <br /> Seepage Bed .......... <br /> ---------------------------------------------------------------- <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Include road Q <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 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. r p--------------------------------------------------------------------- ' <br /> J <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. . .../✓. .�........�. .�............. sq.ft. .............................................................................. <br /> l_ . <br /> 5q�! L o <br /> s <br /> N ° <br /> tR w <br /> J it <br /> -C_ r- <br /> ol <br /> t D <br /> Z <br /> O <br /> r <br /> 7J fnr vM <br /> C c m <br /> n Q < - f <br /> LD. a <br /> " - m g m <br /> 'o m <br /> — m <br /> 0 0 n = 7° <br /> onn - m 3 <br /> on 0 <br /> 0 <br /> m <br /> ........t'u-r' ............................................................. ...................................... . <br /> Signature of Owner or Agent Date — <br /> X <br /> Remarks ......................................................................................................................................................................... T :W m <br /> v <br /> ........................................................................................................................................................................................ <br /> AGO <br /> �. 11 <br /> :O <br /> InspectionDate ....................................... .............. ..(... ....... ............ ................... �i Y o o N m <br /> (� Zoning�or'c) 8 8 8 8 8 8 y <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 />