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7 <br /> Burnett County Office of Zoning Administra or �' 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 nd 2 o� . <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of he n <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws nd 3 _ <br /> re..g.0.a:t.�lon..>.s <br /> hof <br /> r.t-�..e.l.-. .State. of <br /> LV s�.i.s.�c,o.�nsi!n....1.................................. ..... ......................................... ..... <br /> OWNER (Please priori <br /> , <br /> CONTRACTOR or SURVEYOR or AGENT <br /> CIG....u:1.1...:.::. .... ..L�t:....#.........�L................... ...................................................................................... ..... a J <br /> i <br /> ..... ...... <br /> ADDR S S ADDRESS <br /> ........ .....�a.! .:A.'.7..`.... :. '.. .°:.:.......: ...:.r�.::'.Y......................... ...................................................................................... ..... <br /> ADDRESS ADDRESS ,' iZ <br /> ....... ..... <br /> ........................................................................................... . ............................................................................. <br /> PHONE PHONE <br /> .. . ...... ..... .. ............. ....... ............................................................................... ..... <br /> ...... .............................. ........ ........ <br /> PLUMBER WE. . .LL DRILLER _ Tt <br /> .......................................... ..... <br /> ........................................................................................... ........................................... O <br /> ADDRESS ADDRESS �' .0 <br /> .......................... . . . . ........................................................ .-- . . . ............ ... <br /> . ............................ ...... . w <br /> PHONE PHHONE.. Z <br /> DESCRIPTION 4. SanitaryO <br /> Facilities: <br /> 1. Work: 2. New Building Details No. Bathrooms ... ...... o <br /> New Building ,\... Typeyf Construction: No. Bedrooms ... ...... <br /> Addition ....... � .!rt.71.r.:'....:...... ... ......... ...Septic Tank Size Gals. ... ........... <br /> ..... .... <br /> . <br /> Sanitary .......... Size .....�.��.... ft. x ..°�.L ... ft. <br /> Filling/Grading •.••••.... Height......yr.,. Stories .A............ 4a. Absorption Field Site: -- <br /> Moving .......... Area ..... Soil Type ............................. ...... <br /> o <br /> Mobile HomeSlope ................................... ...... » <br /> .......... <br /> Privy .......... 3. Use (describe exactly, 1 •family Perc. Rate ............................ ...... <br /> Well .......... home,garage, motel,etc.) Dry Well �^ <br /> Subdivision ,,,,,,,,,, r` t ,� Seepage Trench o ' i- <br /> .........1 S.I�C...�........................... Privy <br /> ... ...... ' <br /> Camping unit .......... ............... ......... .......................... Seepage Bed ... ...... tJL <br /> ------------------------------------------------------------------- -- :JVc <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fi . A. i i <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is local d at J : <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersect on. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. — 0 ; <br /> ------------------------------------------------------------------- <br /> 5. Lot Size: Fig. A. 6. Location: <br /> ................ ft. x .............. ft. — ............................... sq.ft. ....................................................................... ....... <br /> yE Z.� � ' <br /> l o <br /> l <br /> m <br /> 65 <br /> m Na•c — C any <br /> O N O m b <br /> O fn O D <br /> c'O Nd 9 <br /> `'O _ » lm <br /> v� 0 0 <br /> 3 C <br /> N ; <br /> -, :.... l..r <br /> .................................. ....r........ ........ ........... <br /> Signature of Owner or Agent Date $ <br /> m <br /> Remarks m a <br /> v <br /> .................................................................................................................................................................................. ..... <br /> o . <br /> r o . <br /> ........................................................................................................................................\......:. ....... .................... ..... m <br /> { II <br /> �Gl./h� ....L.......,r. %):r::. T:7.1.�......... . (NTN �86- <br /> N <br /> Inspection Date ....................................... ........-.. .t..... . . ..« . . . . ... mZoning Administrator � $ g � g N <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary fa ilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this app ication 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 bee i 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 AP ROVED. <br />