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Burnett Cotyrty Office of Zoning Administrator T A o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT d 3 <br /> 0 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as '� h <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use e <br /> 'AA .. ......... . ... ............................... ..... .S......C:1.xS..........................................psin. 3 a ` <br /> Ordinance, Sanitation Code,and with applicable County Ordinances and the laws and regulations of the State of Wesco a O <br /> H <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT a <br /> (. a.. 'Pw�F ..... ............................................................................ <br /> .... it ©.......... . . . <br /> ... <br /> ADDRESS ADDRESS :Q i <br /> 1 .....................................................................I....... i l : l" <br /> AD RESS I ADDRESS �� ' <br /> ; I <br /> ................................................�.�.....o................Y.�...e......................................... <br /> PHONE <br /> ... <br /> ....... <br /> PHONEr................................. .................................................................................... ....... <br /> PLUMBER ..TV <br /> ; <br /> WELL DRILLER <br /> .. .. ........................................................... <br /> Q <br /> .......U/ <br /> ADDR nn ADDRESS , m; o. <br /> i. ....................................................................................�....... <br /> 6 <br /> PHONE PHONE <br /> 0 <br /> DESCRIPTION 4. Sanitary Facilities: / ° o 'I ° <br /> 1. Work: No. Bathrooms fE <br /> 2. New Building Details <br /> New Building ... ...... Type of Construction: <br /> No. Bedrooms I <br /> Addition •• ..,.,•,.. Vu-+^--Q- ,,,, Septic Tank Size Gals. �0 ;vJ <br /> .. .... .... ..�........ , <br /> Sanitary Site ....... �• : j <br /> ..��..... (�.].. ft. x ....�...... ft. 1....... <br /> 4a. Absorption Field Site: .0 iO <br /> Filling/Grading ,,,,,,,,,, Height......$:... Stories ... ........... ; <br /> . g Soil Type .... .. ;� <br /> Moven .......... Area ........................................... ))qq <br /> Mobile Home ........ Slope ........F...L.4.... ..... . ...1....... i <br /> Privy .......... 3. Use describe exact) 1 -f Perc. Rate ............'t..L...-l.... .... (vi <br /> Well .......... o e, Stage, motel, etc.) Dry Well <br /> Subdivision Seepage Trench i <br /> .......... .................................................... <br /> __Camping Unit Privy __--_—_--.I.. (\� <br /> .......... .................................................... <br /> Seepage Bed -y 2'� Z <br /> ------------------------------------------------ N <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. Includes road <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway linter- \N <br /> a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING \ : H <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. ---------------- —, o .� <br /> ------------------------------------- -- -- o <br /> 5. Lot Size: Fig. A. 6. Location: 1 °� <br /> ................ ft. x .............. ft. — ............................... sq. ft. ......................................................................:........ !� <br /> ECA i <br /> .�.i i/7t�— a <br /> a \ <br /> �N O <br /> 0 ]Q <br /> 3 <br /> o <br /> 0 <br /> iv d <br /> M N r N D Z <br /> D. lx <br /> w m <br /> - m - m <br /> Z o o D n <br /> 00 $m 3 <br /> F» - _ <br /> INS �p�. 0 m <br /> .... .................... ............ ..K••...•.......................... ................. ................... �o C <br /> Signature of Ow9er or Agent Date <br /> : : <br /> X : m <br /> • /« .. �'L - .�-' .................... .... T <br /> E <br /> Remarks ..:......�..:....................... ......................................................................................................... ,. <br /> ..................................................................................................................................................................................i..... — <br /> �u <br /> ......................................................................................................... ........... <br /> Inspection Date .F.......�.7.. .`..IZ........... . ... >r C <br /> Zoni.ng...dministrator P9'. $ 8 On <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation.test must be attached to <br /> this application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build <br /> ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> with is found to exist. Changes in plans or specifications shall not lie made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />