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Burnett County Office of Zoning Administr for 3 3 <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT » C ;w <br /> M <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and ; I: <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements o the ^` <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3. <br /> regulatiolIns of the State of�isconsm. C — <br /> .4ry S' KU� ✓ ... ......................................................... ....... _ <br /> m <br /> nn n <br /> O "^ "i*nfl CONTRACTOR or SU RV EVOR or AGENT <br /> OWNER (plaese print) <br /> �OXL�`S./............................................................. . .................................................................................. ....... d .� <br /> ADDRESS " i._t <br /> ADDRESS m <br /> IVd �......(U',Zaw�.�..........mN.... S�vy('. . . . . . ......................................................................... ....... d77 <br /> " ' ADDRESS i <br /> ADDRE IZ G 7�I y�� V <br /> PHONE PHONE (� <br /> ....... <br /> . . ............................................................................ . v <br /> ............... ......... ......... <br /> ................. ............................. <br /> ............ .WELL DRILLER . <br /> PLUMBER 'Q� \ <br /> . ................................................................................. ........ —• V <br /> . . . ................................................................................ ADDRESS n o <br /> ADDRESS .� < <br /> . ...................................................................... . ................................................................................. ........ <br /> —' r. <br /> PHONE <br /> PHONE r <br /> DESCRIPTION 4. Sanitary Facilities: <br /> No. Bathrooms ••• •• <br /> o <br /> 1. Work: 2. New Building Details No. Bedrooms ` $ <br /> .• Type of Construction: <br /> New Building ... .. Septic Tank Size Gals. ...... •� <br /> Addition ... ................ ................................... <br /> Sanitary ,..,•,,,,, Size ....�.(...... ft. x ..rZ..Q...... ft: 4a. Absorption Field Site: <br /> Filling/Grading .......... Height............. Stories ............. . <br /> Area Soil Type .......................... ......... i r <br /> Moving o <br /> .......... ........................................... Slope <br /> Mobile Home .......... Perc. Rate ......................... ......... <br /> Privy ,,...,,,,, 3. Use (describe exactly,*1 •family Dry Well 10 <br /> Well home, arage, motel,etc.) Z <br /> Seepage Trench <br /> 2 .......... <br /> Subdivision .......... ...SJ.��.... ................................ Privy <br /> Camping Unit .......... .... IN!+U 9........goo�n............. Seepage Bed ......... , <br /> :JJ --- --- <br /> -------------------------------------------------- <br /> c., <br /> _� c <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fig. A. 9 C <br /> Include road setback,side and backyard dimension and location and setback from all bodies of water. If property is located at C, <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the inters tion. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. O <br /> _____________ ___ <br /> 5. Lot Size: Fig A. 6. Location <br /> ................ ft. x .............. ft. — ............................... sq.ft. ................................................................... ........... <br /> o <br /> o � <br /> � n <br /> w <br /> O <br /> 0 <br /> 0 <br /> See {as <br /> of T yx <br /> O <br /> A <br /> e <br /> M <br /> 1� <br /> m c1 m m 0 cm cm <br /> � ^�n� ''- nm n _nA <br /> SN : `< N O m <D <br /> O HO � D ' '4 <br /> � <br /> ma : <br /> a : y <br /> o co O <br /> m <br /> 7� -1-7 A . <br /> m <br /> m <br /> i natu <br /> n.aiu.. <br /> of Owner or Agent Date No <br /> T ' <br /> �T �� . . . .. .......... <br /> ema s ......... ............................................. ....... <br /> . ....... ......................... ............ ....... <br /> ....................��. .. ..............nmn . <br /> $ <br /> : <br /> N mT N O R <br /> .././........... .. ... <br /> Inspection Date ....................................... ....1 �I1c�.. ....:........ . X�22L . ... . ........ 8 8 8 8 � <br /> Zoning Administrator <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitar facilities before constructi n <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this pplication 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 )een issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plan 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 />