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Burnett County Office of Zoning Administrator 01 M <br /> 0 o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3,. 3 <br /> _ o <br /> TO THE, ZONING ADMINISTRATOR. The undersigned hereby makes application for a Permit for the work described and located as <br /> shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the Burnett County Land Use m C � <br /> Ord' Sanitation and with all other applicable County Ordinances arid s f the Stare of Wisebns'm. 3 <br /> nce, Sanitat � <br /> t .... .... O <br /> . .. ....... . .. <br /> OWNER (plea e�prinU CONT�.R ACTOR or n$IIRVEYOR or AGENT a m <br /> uLar.....� ............................................. d <br /> ADDRESS ADDR SS <br /> i.. <br /> (............................................................................ <br /> ADDRESS ADDRESS <br /> I i i <br /> ........................................................................................... ..................................................................................{ ........ <br /> PHONE PHONE `tV <br /> ........................................................................................... .WE......L.L D.....RI....LL....ER............................................................. ......... <br /> PLUMBER <br /> ADDRESSADDRESS m G) <br /> PHONE PHONE Z <br /> DESCRIPTION 4. Sanitary Facilities: ° o ° <br /> 1. Work: No. Bathrooms I <br /> 2. New Building Details No. i <br /> New Building Type of Construction: No. Bedrooms ......... <br /> Addition .................................................... Septic Tank Size Gals. ......... ? E <br /> Sanitary .......... Size ft. x ft. """"' <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: i <br /> Moving .......... AreaSoil Type .......................... ......... <br /> Mobile Home o <br /> ........................................... Slope ................................ ......... <br /> .......... <br /> Privy .......... 3. Use (describe exactly, 1 -family Pere. Rate ......................... ......... i <br /> Well .......... home,garage, motel, etc.) Dry Well .......... i <br /> Subdivision .......... Seepage Trench .......... <br /> Camping Unit .......... .................................................... Privy ....... <br /> Seepage Bed .......... <br /> ----------------------------------------------- <br /> --- cn <br /> Location of proposed structures and existing structures, well, sewage systems, roads,etc., should be skctched in Fig- A- Include road Q. <br /> setback, side and back yard dimension and location and setback from all bodies of water. If property Is located at a highwai inter- a <br /> section, show the intersecting highways and the setbacks required along them and at the Intersection- CLEARLY LABEL EXI <br /> STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. o <br /> _--______.___.---------- --- <br /> 5. Lot Size: Fig. A. 6. Location: l i <br /> .. ... ......... ft. x .............. ft. . ........ sq.ft. ....................................................................4.......... <br /> {f–f <br /> (j�,J I 4r <br /> Imo)(�,I 7Y <br /> ( N O <br /> i o <br /> s <br /> ji <br /> i / t O <br /> v <br /> m <br /> 1 _I <br /> W Z <br /> m a <br /> aM <br /> Z olio'JI a 70 <br /> V V: a <br /> EF.t ca -i <br /> ca <br /> ........................................................................... .......: :.....�/..::. ......... fill o C <br /> Signature of Owner or,Agent Date i — <br /> X 70 <br /> Remarks ................................................................................................................................................................. ....... � m� <br /> I _. <br /> .............. ..... ..... ...... ............. .... . ..... .... ...... ...... ..... ..... . . _ .......................................................... .... T <br /> Inspection Date .......... .. �a i iJ Y.�..../ t2i `t r`1 .... C u a o' $ o m <br /> ............ r r_...G.'�.... ff t .y�7 0 0 0 <br /> Zoning Administrator :C $ $ $ 0 0 o ti <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures ilinvolving sanitary facilities <br /> before construction can begin. In the case of sewerage disposal systerns, a copy of the percolation test must he attacher) 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 be made without approval of lite Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICEIAND APPROVED. <br />