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Burnett County Office of Zoning Administrator d �Z <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 : o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as < H 0 <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. m <br /> Richard E. La..PI•ante 3 <br /> ............. . ....l�o.P.K.j ......... s 4N... T9r - <br /> a <br /> o <br /> OWNER (please print) { • •................ <br /> CONTRACTOR or SURVEYOR or AGENT a <br /> 556..F.lorence..Avenue............................................ <br /> AoDaess AooREe§b S'.T�.t.......... ................... .. <br /> Mahtomedi,,,MN,.55. ............... . <br /> 115 <br /> ADDRESS <br /> ..................................... .......................................................................................... <br /> ADDRESS <br /> 612-777-2221 <br /> ................................................................ ...................RHO ........................................................HONE <br /> ................. <br /> ' <br /> PL . .4..T. .. ..fl... ..........................._.............. ..........................................UMBERWELL DRILLER A5, 'i ?Lu <br /> .�G. : <br /> w <br /> ...................... . .... <br /> .......... .... <br /> ........ . .. �1.. <br /> ........ . <br /> . .... .... .. . . . <br /> ADDRESS . ............................ .. '..5.,...... Y..C.Y..Lo.F.!>.S.S.......... U o <br /> ADDRESS <br /> m 0 <br /> ........................................................................................... ^. < r� <br /> PHONE . .......................................................................................... O O <br /> PHONE O <br /> DESCRIPTION ow r- <br /> 1. <br /> 4. Sanitary Facilities: o <br /> Work: 2. New Building Details No, Bathrooms <br /> New Building � <br /> No. Bedrooms <br /> O <br /> ...n,... Type of Construction: <br /> AdditionSeptic Tank Size Gals. <br /> .......... .................................I...... ........... <br /> Sanitary „}�,•„ Size ....X.41... ft. x .....{.,0.... ft. <br /> .......... <br /> Filling/Grading <br /> .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving - <br /> .......... Area <br /> . . .. ...... , Soil Type ...................................................... <br /> Mobile HomeTiv/ . Slope ................................. . r <br /> o <br /> Well ,,.,,.,.., 3. Use (describe exactly, 1 -family Fare. Rate ................................... o <br /> Well home,garage, motel, etc.) Dry Well ,,,,..,,., <br /> .......... <br /> Subdivision t(eM� Seepage Trench <br /> Camping Unit Privy <br /> J.................................................... ..........P P y <br /> _____________ Seepage Bed ,..... r <br /> Location n( proposed structures and existing structures well, sewage systems, roads, etc.,should be sketched in Fig. A. Include road <br /> c <br /> setback, sloe and back yard dimension and location and setback from all bodies of water. If ro art Is located at a highway inter-EXISTING a <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL `N <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. �+ H' <br /> --------------------------------------------------------------- `r\ <br /> 5. Lot Size: ® ' IL/1 <br /> Fig. A. 6. Location: / GC <br /> /D...S..... ft. x ..Y37... ft. - ..... .'d^`..f1CrzS. sq. ft. Loc K (v or Y O <br /> .................. ... ...................................... ................ <br /> � m <br /> n <br /> N \ o. <br /> o ^ O <br /> O � <br /> :0 <br /> C o <br /> to>4s a L! <br /> Eril$TrNs R f KrSTiN� o T O <br /> r c�eiv <br /> d <br /> t a u Al - - <br /> q (T w <br /> m L <br /> Z O O <br /> o � <br /> S <br /> Signature of Owner or Agent " .. .. :� o ' <br /> Date C <br /> Remarks .......�...- - Px <br /> ...�� .... <br /> . ..... ... .. D <br /> cwta-r�2 a .... ..v� ......... .......................... <br /> Inspection Date ...... r N <br /> 5 l '...... j m <br /> u o 0 <br /> Zoning Adtrator 8 0 8 0 $ cl) <br /> NOTE: / /F:.ir.ri r�i <br /> p eflm lnary site Inspection must be Tfiade and site approval granted on ell structures involving Sanitary facilities <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation lest must be attached to <br /> this application before a permit will be issued. Do not purchase or install a septic tank, do dry 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 be made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />