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Burnett County Office of Zoning Administrator in -0 o <br /> o t d— <br /> APPLICATION FOR SANITARY — LAND .USF_ BUILDING PERMIT 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a o <br /> Permit for the work described and located as shown herein. The undersigned agrees that all \ <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, � ?,✓ <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- -° <br /> lations of the State of Wisconsin. a _ 0 <br /> Q� <br /> ('. . . .pl. . .C%. . .jease print). . . . .. . . . . . . . . . . .Contractor. . . . . . . .or S. . ur. .veyor. . . . . . . . . . . . . . . . . . . . . . . <br /> Owner or Ajnt ( N vl <br /> . `�ess . . . . . . . . . . . . . . . . .A. . . .re <br /> ddss. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i <br /> Addra _ <br /> • a. .4. .7.3. <br /> Phone } 7p_ i/��2� 2 Phone <br /> Pluker. . . . . . . . . . . . . . . . . . . . . . . . . . . Well Driller. . . . . . . . . . . . . . . . . . . . . . . . . . . . :\J ' <br /> . \�c) <br /> Address Address <br /> m <br /> ° 0 o <br /> o <br /> . .one. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Ph. one. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ( •. <br /> PhN m �• <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: /L ° <br /> Type gf ConstructionC No. Bathrooms • a o o ° <br /> 1. Work - / . . . . . . .P . No. Bedrooms <br /> New Building 4� Size Y ft. x . .�z. ft. Septic Tank Size Gals. . . . . . . <br /> Addition Height . . . . . Stories . . . . . . �. v� <br /> Sanitary Area . . . . . . . . . . . . . . . . . . . 7a.Absorption Field Site: / m <br /> Filling Soil Type . . `� ^ ` ' \ o <br /> Moving . . . . . . 5. Permits Required Slope <br /> . . . . .J. . . . . . . . <br /> Grading . . . . . . Subdivision Perc. Rate . . . . . <br /> t� Dr Well ✓ <br /> Mobile Home Sanitary Y • • • • • • <br /> Privy . . . . . Building Seepage Trench . . . . . . m m :Il <br /> 64 <br /> Well ( Well (.l, Privy <br /> Subdivision Other (Specify) Seepage Bed . 8xo� / o <br /> CD <br /> Conditional c m <br /> 2. Classification Land Use . . . . . . ) a °, <br /> Zoning Dist. . . . . . . o <br /> 6. Use (describe exactly, <br /> 3. Lot Size home, motel,etc.) FOR COMMERCIAL USE ° <br /> ,��• ft. x . . . . . . . . ft. Plans Submitted . . . . . . I <br /> sq. ft. Plans Approved . . . . . . <br /> ---- ----- -------------------- — <br /> Fig. Location of proposed structures and <br /> existing structures, well, sewage sys- o <br /> tems, roads, etc., should be sketched <br /> in Fig. A. Include road setback, sidePA s <br /> and back yard dimension and location � <br /> /In and setback from all bodies of water. f <br /> If property is located at a highway in- <br /> tersection, show the intersecting high- <br /> ways and the setbacks required along <br /> them and at the intersection. <br /> PERMIT FEES `• <br /> Subdivision . . . . . . . . . $15.00 <br /> S U i Land Use . . . . . . . . . . . 1.00 :\ <br /> A Building . . . . . . . . . . . 5.00 :t^ <br /> Sanitary . . . . . . . . . . . 10.00 <br /> �— l�� p $ • �` <br /> Well . . . . . . . . . 5� <br /> Septic Tank 10.00 <br /> dXay g� Combination Building, Sanitar <br /> Privy <br /> and Well 15.00 <br /> S <br /> . 5.00 <br /> A� VVVVVV .....k. _ / ..........�.,...�......... <br /> ...�r /. iv. <br /> gnature of Owner or Agent <br /> . / ning miniis'tlr!at <br /> or <br /> �..: r �........... In ector G�Inspection Date ... .. ....... . .....�......................... <br /> 17 <br /> Remarks . .. . � . ..!....<.F. J .. <br /> ..![„r...�L/...... <br /> ........................................................................................................ <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 />