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F/1"J C--,Lf7,. <br /> Burnett Cotan y Office of Zoning Administrator v a, o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT3. <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and located as N <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use E W <br /> CD <br /> Ordinance, Sanitation Code,and with all other applicable County Ordinances and the laws and regulations of the State of Wisconsin. 3 0 V.\ <br /> OWNER (please print) CONTRACTOR or SURVEYOR or AGENT a n �o 1A <br /> 4350..Qhi.paSn...Ave..5....Minn....MN 55407 a p <br /> co <br /> ADDRESS ADDRESS <br /> CD <br /> /.) <br /> ADDRESS ADDRESS k C7 <br /> z <br /> PHONE PHONE <br /> Donald Daniels kx -3 <br /> PLUMBER WELL DRILLER <br /> 0 <br /> ADDRESS ADDRESS N 2 o <br /> 715 463-233.3 <br /> PHONE PHONEZ H r <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: 2. New Building Details No. Bathrooms ....1..... <br /> New Building Type of Construction: No. Bedrooms ...2..... 4 s3 g <br /> Addition Septic Tank Size Gals. .75.p.. V <br /> Sanitary ,..X..,. Size ft. x ft. v1 <br /> Filling Height Stories 4a. Absorption Field Site: �0 <br /> Moving Area Soil Type r <br /> o <br /> Grading Slope <br /> Mobile Home 3. Use (describe exactly, 1 -family Perc. Rate -... w <br /> Privy home,garage,motel, etc.) Dry Well Well Seepage Trench \z,:s <br /> Subdivision Privy _ <br /> � <br /> Seepage Bed '�'� <br /> 4. P Co <br /> Location of proposed structures and existing structures,well,sewage systems, roads,etc.,should be sketched in Fig. A. Include road0 c <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property is located at a highway inter- 1,....) o- <br /> section, show the intersecting highways and the setbacks required along them and at the intersection. CLEARLY LABEL EXISTING y <br /> 4,. <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o' <br /> 5. Lot Size: Fig. A. 6. Location: 6 z <br /> ft. x ft. — sq.ft. CbV <br /> CD <br /> C, <br /> N1-k- <br /> 0. <br /> 02. gou <br /> C Z <br /> ° <br /> T W <br /> 10 <br /> N. � <br /> F, <br /> T <br /> r <br /> N c° <br /> a' <br /> m Cry coZ <br /> CD 0 m 6c m <br /> Cl N a Cr Q< i? <br /> -O O1 <•r E. 0 -ci <br /> 0 N N CD * m <br /> o j <br /> Om . `D 717 <br /> ` / (Pio) <br /> 6 -2,..5.---2/ v, 0 <br /> F C <br /> Signet.re of Owner or Agent Date <br /> Zemarks � X03 x : :co N: •: m <br /> CD O C <br /> to _ <br /> O ° . :`a <br /> -in Datec??4,-/-z40 /4 ' ,12.-n.•.e.. iv,-,T) — 0C10NT <br /> 0000cnm <br /> M <br /> Zoning Adminis ator A' 4 <br /> .0 .0 <br /> )reliminary site inspection must be made and site approval granted on, all structures involving sanitary facilities <br /> ruction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached to <br /> n before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any build- <br /> nit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed here- <br /> exist. Changes in plans or specifications shall not be made without approval of the Zoning Administrator. <br /> 'TEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />