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Burnett'County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT m 3• <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and '� o 0 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the m <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the State of isconsm. g <br /> '.�............. u.�K...fl.�.h..r�............ ........4.5 {'...................................................................... <br /> 6 <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT <br /> X... .......................... ............................................................... ;oQ <br /> ADDRESS ADDRESS is l <br /> cs✓ [/7.... FV, ......... ?Y.���: .............................. . . . . .. ................................................................................. (e/) <br /> ADDRESS ADDRESS :c'o <br /> OQ <br /> ......................................................... ............................................................................................ L c� <br /> PHONE PHONE t ;' <br /> 1 . ?e... /.29........................................ ............................................................................................ oQ <br /> PLUMBER WELL DRILLER ' <br /> :• <br /> BA.Y Z..... 3...... o <br /> _. <br /> ADDRESS ADDRESS C <br /> ....................................................... . . . ...................................................................................... <br /> PHONE PHONE Z r <br /> DESCRIPTION 4. Sanitary Facilities: / ° o <br /> 1. Work: 2. New Building Details No. Bathrooms ...... = o <br /> New Building „ ,,✓,,,,, Type of Construction: No. Bedrooms ... .. <br /> Addition ..................................... Septic Tank Size Gals. /+. V <br /> .......... �999pp pO <br /> Sanitary .11....... Size ...L.2a.... ft. x ....V.l..... ft. .......... <br /> Filling/Grading •......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ......................................... Soil Type .................................... : .Q r <br /> Mobile Home <br /> .......... Slope .......................................... <br /> m <br /> Privy .,.,,,,,,, 3. Use (describe exactly, 1 -family Perc. Rate ................................... � <br /> Well .......... home,garage,, otel etc.) Dry Well .......... <br /> Subdivision PA.,/ Seepage Trench o <br /> .......... ...Z.. .Ql.XI... . hA!XI ....... <br /> .... . Privy .......... •\ i/” <br /> Camping Unit .......... 3 <br /> Seepage Bed _ ____—_—_ <br /> ------------------------------------------------------------ — Ch i `\ <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersection. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. <br /> ---------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: O ` <br /> ................ ft. x .............. ft. . ............................... sq. ft. ............................................................................... i <br /> Ol($oa b J <br /> J <br /> W <br /> " O <br /> Le <br /> , L D <br /> V71 <br /> Z � <br /> � d <br /> J <br /> L <br /> Aj <br /> mu)MCA o cm cD-0 <br /> o a < J J o -. _. m <br /> m �n�c -� nm nny <br /> 9 0< d C y J J 3 <br /> 04 O mO <br /> O w0 D <br /> �J fn n .� <br /> o , a : <br /> C 0 p <br /> / � � f� � 1 ............ p <br /> n <br /> m <br /> Signature of Own or gent Date 8 <br /> y <br /> RemarksL�J..../..�. . .�.....1r.cP.-L:a7...................................................................................................................... <br /> N <br /> U : O <br /> ........................................................................................................... ... ................. ...... <br /> ,// �W 8 <br /> Inspection Date ........... r ......... .. ......:.... ........ N N V• O O N m <br /> .. ....................................... O C <br /> Zoning dmimstrator 8 8 8 8 8 8 to <br /> NOTE: A preliminary site inspection must be made and site approval 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 application 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 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 />