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Poirnett County Office of Zoning Administrator 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT m 3 tJ <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described ntl 4� <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the r$ <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws nd 3 ) <br /> regulations of the State of Wisconsin. _ a <br /> // '/l/7�3f�fls�ll.......................................... ..................................................................................... ...... <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT <br /> ,5-OAs.gP..n�!?r. ..42!.?.G................................. ... ................................................................................. ...... d <br /> ADOIiESS ADDRESS <br /> aQcr &.m...n1.......s.. -V4.�..................... .................................................................................... ....... <br /> ADDRADDRESS <br /> ...... ....... <br /> ........................................................................................... .P. ..................................................................... .Y J <br /> PHONE HONE...... <br /> PLUMRER................................... ....................................... L.WELDRILLS..R ... <br /> ... .................................................. .... <br /> .. Cw ' <br /> .......................................... ....... <br /> ........................................................................................... . ..... <br /> D. .. ............................ <br /> O <br /> ADDRESS ADRES.. ..S M o <br /> .. .. .................................................................................. ....... <br /> ........................ <br /> . .................... .................................. .......... . <br /> PHONE PHONE <br /> DESCRIPTION <br /> 4. Sanitary Facilities: <br /> ° o <br /> v <br /> 1. Work: 2. New Building Details No. Bathrooms .. ....... 'o <br /> New Building .......... Type of Construction: No. Bedrooms . •••.•... $ <br /> Addition Septic Tank Size Gals. . ........ i <br /> .......... .................................................... <br /> Sanitary .......... Size .............. ft. x .............. ft. . ........ <br /> Fltlingf Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving Soil Type ........................... ........ i r <br /> Slope <br /> Mobile Home .................................ate ........ <br /> Privy .... 3.3. Use (describe exactly, 1 -family <br /> Perc. Rate .......................... ........ <br /> Well home gars e, otel,etc.) Dry Well ....• <br /> .......... Z <br /> Subdivision - Seepage Trench . ........ <br /> Camping Unit .......... ........... .... y; Privy <br /> .... ... ..R.i.Y..`/}�J.................. Seepage Bed <br /> ________________________1---___-____-____--__--__-- ;� •N <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in F g. A. <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is loc ed at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the interne tion. (�'I <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. O <br /> _______________ ____-_________-___---___--_______ <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ........ . sq.ft. J <br /> n <br /> o <br /> 0 <br /> � V <br /> O ) <br /> O <br /> 77 : _ <br /> r vq <br /> ' m Cltl�Jl ; /�I d � <br /> s J n�i a m a n <br /> 50r �� u'etl y ' 3 <br /> = $0 0omm <br /> - N <br /> S' trm. I'i tiro-f2, o� � a . � <br /> Na : y <br /> $ 2 — m <br /> 0 � <br /> o m y <br /> K m <br /> .................................. ...................................... <br /> Signature of Owner or Agent Date o <br /> T N <br /> n ; <br /> Remarks <br /> w � <br /> ............................................................................................................................................................................... ........ o : o <br /> ..................................................................................................... .... ................. ....nn ...................I.......... ........ [Nli . . . tNT <br /> Inspection Date ....................................... :.. g . . <br /> Zonin Admintrs,�rator � $ $ $ $ $ H <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities before onstruction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this ar plication before a permit will <br /> be issued. Do not purchase or install a septic tank, do any plumbing or start any buifdinguntil a permit has been issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or specifications 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 />