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Burnett County Office of Zoning Administrator �' c <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3. a <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and '� M <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 and 3 `a <br /> regulations of the State of scon in. p <br /> �+ _V <br /> y <br /> Q.��.(A.... s....l � 1 ::L ..... . ..� . /�{Ili Z> <br /> OWNER Ipleess print) I- CONTR, CTOR or U 7YOR o AGENT <br /> A DRESS J : ADDRE <br /> r.0 . ..1.� ��..... �;, a .l r�..... 43.0.... ......... .. . 5 ,....yti ....X31. '. ............ <br /> G <br /> ADDRESS ADDRESS : I <br /> PHONE................................................................................ PHONE................................................................................ J i� <br /> . . . . ... . . . . . . . ... <br /> PLUMBER WELL DRILLER > <br /> i ^ <br /> ADDRESS AODR ESS A C) . <br /> PHONE PHONE _ <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> t. Work: No. Bathrooms <br /> 2. New Building Details c <br /> New BuildingT No. Bedrooms <br /> Type of Construction: .......... Q� <br /> Addition .................................................... Septic Tank Size Gals. .......... i <br /> Sanitary .......... Size .............. ft. x ft. .......... <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area Soil Type .................................... i (` <br /> ........................................... <br /> Mobile Home Slope .......................................... <br /> .......... <br /> Priv Perc. Rate ................................... <br /> Privy 3. Use (describe exactly, 1 -family : k <br /> Well .. ..., home,garage,motel, etc.) y <br /> Dr Well .......... � : <br /> Subdivision „ Seepage Trench 0 <br /> .......... o <br /> Camping Unit .......... .. Privy .......... <br /> .................................................. <br /> Seepage Bed .......... <br /> ----------------------------------------------------------- p (1 <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Q c <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is located at o. •� <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. o <br /> _____ __________________________________________ ' b <br /> 5. Lot Size: Fig. A. 6. Location: rr <br /> ................ ft. x .............. ft. . ............................... sq.ft. ............................................................................... <br /> � <br /> CnPc� csf ry'y-\ N <br /> O <br /> VD <br /> _ 0 <br /> 0 <br /> f <br /> E�U <br /> Y Z G <br /> 0 <br /> D <br /> v <br /> m <br /> m c m m n cm S.S. M <br /> c o n a y <br /> C p o � 3 <br /> O N •< N O u1 m <br /> O w0 � � D � "I <br /> n ; y <br /> o c m <br /> : E5 <br /> = c <br /> x n : m <br /> S <br /> ..igna.... tur. 't'u"r.....f...O...w..ner.. ..or.... ...A..gent..... ............................... .................D. .................. m <br /> e oat.. e <br /> Remarks ............... .. .......... .y.. ..... ..................... =- <br /> e �� c>r,n� �� r7� <br /> .............. . TY.0••�J...'�...:...J.. e........... r� .7............. <br /> o Nv mInspection Date ....................................... .... Xe( L.J. ,..... <br /> Zoning Administratm <br /> 7 $ $ $ $ $ $ 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 />