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541 (evil:i /IR- <br /> Burnett County i�ftice of Zoning Administrator <br /> CD CD d 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT -0 <br /> 7 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a - o N , <br /> Permit for the work described and located as shown herein. The undersigned agrees that all d N <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, A-cpcp <br /> Sanitatio Code, and with all other applicable County Ordinances and the laws and regu- o_ <br /> lations the State of Wis nsin. <br /> 3 d 0CD <br /> �" co <br /> Owner or Agent please prin aster o Surve or '^ <br /> .7aLtitrn m • <br /> Address Address a \,,' . <br /> d <br /> Phone Phone <br /> 1 R Plumber Well Driller <br /> Address Address CD G) <br /> n 0 <br /> r+ < <br /> o ,.. <br /> Phone Phone CD H I- <br /> 0 r, 0 <br /> CD o - <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: -a <br /> Type of Construction No. Bathrooms o z 0 <br /> 1. Work No. Bedrooms ° CD <br /> New Building Size ft. x ft. Septic Tank Size Gals. \ .< W <br /> Addition Height Stories <br /> Sanitary Area 7a.Absorption Field Site: m <br /> Filling Soil Type o <br /> Moving 5. Permits Required / Slope <br /> Grading Subdivision t� Perc. Rate <br /> Mobile Home Sanitary Dry Well -n CD CD <br /> Privy Building Seepage Trench `D CD <br /> Wellf Well Privy )1,..) <br /> Subdivision /.. Other (Specify) Seepage Bed op' <br /> Conditional o N cn <br /> C CD <br /> 2. Classification fe �i Land Use a _ <br /> Zoning Dist. 'Z 0 <br /> 6. Use (describe exactly, 1 -fam. N' <br /> 3. Lot Size home, motel,etc.) FOR COMMERCIAL USE o <br /> ft. x ft. Plans Submitted l� <br /> sq. ft. Plans Approved <br /> Fig. A. Location of proposed structures and H <br /> existing structures, well, sewage sys- 0 <br /> tems, roads, etc., should be sketched c <br /> in Fig. A. Include road setback, side = <br /> !'� •bit), /{� and back yard dimension and location o <br /> z (�'/ / ' and setback from all bodies of water. <br /> If property is located at a highway in- <br /> / tersection, show the intersecting high- Q <br /> i . /i ways and the setbacks required along <br /> them and at the intersection. <br /> (� n N3 PE- 11 T FEES D <br /> w Ivco <br /> 63_ <br /> Subdivision.411W+ $2.00 per lot. <br /> rr��_ 1_0- .., 5- Land Use $10.00 <br /> 10.00 \ <br /> �l1 Building <br /> 7 Sanitary 20.00 <br /> , ,-- U a Well 10.00 <br /> �, Septic Tank 10.00 <br /> Privy 5.00 <br /> 777 61/(1., r. i ' <br /> Signature of Owner or Agent Date Zonin. ,:�#strator <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 he made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />