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Burnett County Office of Zoning Administrator �'N ; , / Id" H z <br /> co Co m ° <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT -0• 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a -I �. o "\ <br /> Permit for the work described and located as shown herein. The undersigned agrees that all a, N <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, c <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- p ° <br /> lations f the tate of y1/ilconsin. 3 ° 0 <br /> l' l Q + G l hatter Nci, <br /> ( c% co <br /> Ownei_o_r �g nt ( Contractor or Surveyor c <br /> alit / /14/V a (.2 <br /> Address 55/iAddress a : t <br /> 17/- 6. om, <br /> `' s . <br /> Phone Phone 1 wA <br /> 53 nNi <br /> Plumber Well Driller <br /> Address Address Ni c2. o gs, <br /> Phone Phone see ei�i � Do^Q :9:: <br /> 3 o <br /> D ESC R I PT ION 4. Building Details 7. Sanitary Facilities: <br /> Type of n t �,t���.e No. Bathrooms o z 0 <br /> 1. Work ( /!f /y+� No. Bedrooms • • • . . ° Co <br /> New Building Size . . ft. x . .s/. .V ft. Septic TAnk fi��als. � .� <br /> Addition Height Stories t� ,� <br /> Sanitary Area 7a.Absorption Field Site: iN m (r <br /> Filling Soil Type o <br /> Moving 5. Permits Required Slope f <br /> Grading Subdivision Perc. Rate bq <br /> Mobile Home Sanitary Dry Well ��Co )_.1 <br /> Prvy Building L- Seepage Trench `D2. 1 <br /> Privy t <br /> ify <br /> Well Well L� I <br /> Subdivision Other (Specify) Seepage Bed o <br /> o <br /> ConditionalN N <br /> 2. Classification p _ Land Use r _ ; co- -_ <br /> Zoning Dist. •-� \ ��: ° <br /> 6. Use (describe exactly, 1 -fam. C� ° <br /> 3. Lot�Sj,�,e c) h me, motel,etc.) FOR COMMERCIAL USE CCTT ° <br /> Com'(1' � <br /> ft. x . ft. /�do/1y r �n ? Plans Submitted �(� <br /> sq. ft. l Plans Approved NIS <br /> gitteze. <br /> _pi - <br /> i9• A. Location of proposed structures and <br /> 1' . ----i) <br /> ��� � "� existing structures, well, sewage sys- •.. 0 <br /> tems, roads, etc., should be sketched <br /> f in Fig. A. Include road setback, side =• <br /> and back yard dimension and location -o. <br /> and setback from all bodies of water. <br /> f If property is located at a highway in- . k.2, ih <br /> k____.,g,a 1Ivin1 tersection, show the intersecting high- ' \C 036 �X� ways and the setbacks required along <br /> C �, el-bi them and at the intersection. <br /> r� m <br /> 4 j. Iticiei �� PERMIT FEES <br /> Q Subdivision $ Coto <br /> 4) 4-7,--(' Land Use •0.00 <br /> Building AM: :: <br /> Sanitary <br /> Well /(i - — <br /> Septic Tank 10.00 <br /> Combination Building, Sanitary <br /> and Well 'tom <br /> Privy 5.00 <br /> ..jr- E—aLji(A6-' oy, . 77 <br /> i • <br /> Signature of Owner or Agent Date Zoning0 ' 'lel <br /> s inistrator <br /> Inspection Date Inspector <br /> Remarks <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 be made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />