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6 'n 'P <br /> Burnett County Office of Zoning Administrator in <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3• <br /> M � <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application fora Permit for the work described nd <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws nd 3 ; <br /> regulationBof the Stat nsi �� l » m <br /> ..... ..................................... ......................... ........................................................ ...... 6* <br /> OWNER (plea»print) CONTRACTOR or SURVEYOR or AGENT <br /> def ( t)+ , <br /> �• � • � • ADDRESS <br /> ADDRESS SS !o <br /> . . . ................................................................................ 'A"'D" .............................................................................. ...... Z <br /> ADDRESS ADDRESS <br /> .... <br /> PHONE................................................................................ .PHONE.................................................................. ... <br /> : V 3 <br /> ........................................................................................... . ....................................................... .......... <br /> ...... ....... ...... <br /> PLUMBER WELL DRILLER <br /> O <br /> ........................................................................................... .................................................................................... ...... _. <br /> ADDRESS ADDRESS C :�. <br /> ........................................................................................... . . ............................................ ............................... ....... .: <br /> PHONE PHONE.... Z N r <br /> DESCRIPTION 4. SanitaryFacilities: ° c ° <br /> No. Bathrooms T <br /> 1. Work: 2. New Building Detailz 4 """' J 'o i <br /> New Building Type of nstrucY n: No. Bedrooms 3 711 .•�{•`•p'}� <br /> Addition ......... Septic Tank Size Gals. .... •� .r ., <br /> Sanitary .......... Size ..� :..... ft. x ....�.`..�... ft. .. ....... i� <br /> Filling/Grading Height............. Stor' s 4a. Absorption Field Site: <br /> / PP Soil Type ............................ ...... r <br /> Moving .......... Area ......... KA ...................... - T <br /> O <br /> Mobile Home Slope ....................... <br /> .......... ./�:::....• p <br /> 'y5 <br /> Privy 3. Use (describe exactly,'1 •family Perc. Rate ......... <br /> Well .......... home,garage, motel,etc.) Dry Well <br /> Subdivision ,,...,,_,_ <br /> Seeps tench .... <br /> Camping Unit .......... �............... Pr• .. .... _ : . <br /> L ,�,�,,�- .. <br /> ....5.... . ... .............. eepage Bed .. ....... <br /> ------------------------------------- <br /> Location of proposed structures and existing structures well sewage systems, roads, etc., should be sketched in Fi I. A. y�•� .� <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is loca ed at 1 <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersec ion. 6` : „<-, <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. O, <br /> T. <br /> ------------------------------------------------------------------- -- <br /> 5. L S' e' ,1 Fig. A. 6. Location: t i <br /> .t.�.�...... ft. x ft. - sq.ft. <br /> ............................... ...................................................................... ........ O <br /> n <br /> N O <br /> o f) O <br /> 7 <br /> See- AT�'� P�t- Pia^- o <br /> 0 <br /> also SSE <br /> Dbv <br /> s <br /> Z O <br /> O <br /> p <br /> d <br /> m Nn < -' nm nnA <br /> � <om c � 3 3 <br /> `G N 10 <br /> zg : f0 <br /> $ 2 <br /> Om <br /> c <br /> a <br /> _x n : m <br /> ............ .. .... ............. .......... . . ......... ...... ...................................... > O <br /> Signature f Owner or Agent Date $ <br /> Remarks ..... m a <br /> ................................................................................................................................................................................. ...... o : o <br /> o . <br /> G N Oo N N m <br /> Inspection Date ....................................... <br /> m <br /> ator............... .. $ $ $ $ $ yn9mi <br /> . �tr. om <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary f icilities before constructio <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this ap lication 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 be n issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans o specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE ANDA PROVED. <br />