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Burnett County Office of Zoning Administrator a ` 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 z <br /> a <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as — [`t� <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 o,pt <br /> Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 `, 'Ja <br /> Hope Presbyt4i Church Self u o <br /> .15 <br /> OWNER (please print) CONTRACTOR or SU RVEVOR or AGENT m _ Ei. M <br /> 7132 Portland Ave. So. <br /> ...........................—.......... .ADD......R.. .............................................................................. ° x <br /> ADDRESS ES....S <br /> Minneapolis, M551+23 N fD :o <br /> — j� <br /> ADDRESS ADDRESS <br /> ........................................................................................... . ... .................................................................................. <br /> PHONE PHONE.... .. ' tp <br /> ........................................................................................... . ............... ......................................................................... <br /> C <br /> :M <br /> PLUMBER WELL DRILLER.. :rp <br /> ........................................................................................... .AD...DR. :H. <br /> ADDRESS . ... ................................................................... 3 <br /> .......... <br /> ESS..... ' <br /> 0w <br /> m <br /> o <br /> :n <br /> PHONE PHONE H � <br /> DESCRIPTION 4. Sanitary Facilities: ° o 0 n <br /> 1. Work: 2. New Building Details No. Bathrooms ...Q..... <br /> :� <br /> New Building No. Bedrooms o <br /> .......... Type of Construction: q <br /> Addition x Septic Tank Size Gals. .......... :w <br /> < i i <br /> Sanitary .......... Size .............. ft. x ft. D <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: x i o <br /> Moving Soil Type ............... <br /> .......... .......................................... ................ <br /> Mobile Home Slope ........................ .... . ............. o <br /> .......... r :r. <br /> :Q <br /> `v w <br /> Privy .......... 3. Use (describe exactly, 1 -family <br /> Pere. Rate ................................... <br /> Well home,garage, motel, etc.) Dry Well ,....... :t,l, <br /> SubdivisionSeepage Trench .,.,...... io <br /> ,..,..,... Q <br /> .ra,£..t...H..A111........................ r <br /> Camping Unit .......... Privy ' <br /> __________________________________________________ Seepage Bed— ......... a�� <br /> ------- r 2 to <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig_ A. Include road 'J Igr141. <br /> setback, side and back yard dimension and location and setback from all bodies of water_ If property Is located at a highway inter- r� ix a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING OO :N 5 <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. r <br /> 0 <br /> 5. Lot Size: Fig. A. 6. Location: UUU :w <br /> ................ ft. x .............. ft. — sq.ft. <br /> D MUD R.i LAtb kiol,. o°o ^a 0 <br /> o <br /> � y <br /> N <br />)\"XX1 <br /> 750 p <br /> W <br /> C <br /> J <br /> Z <br /> oY4X55 �- ° ;o <br /> EXIST' h <br /> Bldg I " <br /> dL <br /> w <br /> MOO i <br /> > z00' 25 < i <br /> :0C N 9 < d W Z <br /> I ISnnq — M a s = a f <br /> 61dc� caai ® m m <br /> m <br /> 85' o a � M <br /> t» - 'n $ <br /> .....Mud HCM IJyY-ems -4, M <br /> M <br /> !'.. .... ... ......1�.'�............................ ......` .Zq�...6..... o c_ <br /> Slgnature of Owner or Agent Date <br /> X 3J <br /> Remarks T : m <br /> ........................................................................................................................................................................................ FA <br /> ....................................................................................................G.% .. nnmt .... OI <br /> ? u u oiro�� mInspection Date ....................................... ....................... ra <br /> nrator $ $ $ ilZogd <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 />