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Burnett County Office of Zoning Administrator �' o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3• <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 0 <br /> located as shown herein. The undersigned agrees that all work shall be don in accordance with the requirements of the i <br /> Burnett my Land Use Ordinance, Sa tion Code, and with all otAabl ounty Ordi P and the laws and 3 <br /> regula ' Sta/te/_�g�._I/s" sin. d <br /> .. .. ./......la' .'..K!R!rr'..!41.....t...11. ... .�.rte..!.'... .......... �.4r'�/..:.:."... . 5...........NER Ipleex print) CONT SUR VOR or AGENT i \ <br /> ... ....o... .....................::... .. ........................................... d <br /> ADD S ADDRESS m _, <br /> �rf/.?C!! O. s /.7t�. � T i <br /> /' ,3�- .............................mar*. ........................................... ' <br /> AD RESS ADDRESS <br /> .............. ................................................................................ <br /> PHONE ��l�/�// PHONE : _ \ <br /> .. .. ..................................... .... ...... ..... . . . ..................................................................................... <br /> PLUMBER WELL DRILLER <br /> i <br /> ADDRESS ADDRESS G <br /> ^. < <br /> ........................................................................................... . ................................................................................... <br /> PHONE PHON........E Z o r <br /> DESCRIPTION 4. Sanitary Facilities: P o ° V <br /> 1. Work: 2. New Building Details No. Bathrooms .......... e New BuildingNo. Bedrooms ""•""'""•""'...... <br /> g .... Type of Conduction: <br /> Addition � /' t Septic Tank Size Gals. <br /> .......... .......... .................... .......... <br /> Sanitary .......... Size ..�i..'J`:...eft. x ...RZ..C�.. ft. .......... <br /> FllungfGrading .......... Height...../A... Stories ..../........ 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... Soil Type .................................... <br /> ........ i o <br /> i <br /> Mobile Home Slope .......................................... 0 <br /> .. <br /> m <br /> Privy .......... 3. Use (describe exactly, 1 -family Perc. Rate ................................... � <br /> Well .......... home,garage,motel, etc.) Dry Well .......... <br /> SubdivisionSeepage Trench z <br /> .......... 0 <br /> .......... ............ ................................... <br /> Camping Unit Privy <br /> �F/. .Q:..................... .......... <br /> .......... Seepage Bed .......... <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. :CC <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at :ty <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 /> --------------------- _ ____ _ i <br /> 5. Lot Size: Fig. A. 6. Location: 17 <br /> i <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... <br /> G <br /> C7 � <br /> n <br /> N O <br /> O J <br /> 2. <br /> : i <br /> Z <br /> Z Z <br /> 0 <br /> d <br /> m <br /> n �cr J n -. _. m <br /> m �n•c - nm aay <br /> O < d <br /> co J J ; <br /> S N K O Z m <br /> O NO D ' <br /> u,J ' Na <br /> ,, n ; y <br /> o m0 <br /> ...... ..... t0�/ Q�........... <br /> >1 ? <br /> Signature of O er or Agent Date $ <br /> Remarks <br /> ........................................................................................................................................................................................ <br /> .................................................................................................... . ... I...K................. <br /> Inspection Date ....................................... .. ...... <br /> ....... . . �,,.... ... <br /> Zoning Administrat�r 67� "b g o $ g <br /> NOTE: A preliminary site inspection must be made and site apD al 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 />