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Burnett County Office of Zoning Administrator ./ o -1 Z <br /> � m ° o <br /> WPLICATION FOR SANITARY — LAND USE — 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 N \ M <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- v ° <br /> latns of the State of Wisconsin. 0- <br /> 0 <br /> 3 m <br /> wner or Agent (please int) Contractor or Surveyor N Z <br /> c : \ <br /> Z <br /> CL <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Ad ress Address a R ;� C <br /> m <br /> Phone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Phone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> fmber Well Driller <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n o <br /> Address Address : � 0 ;'O <br /> . . . . . . . . . . . . . . . . . . . . . . . N ° <br /> Phone Phone m 0 <br /> DESCRIPTION 4. BuildingDetails7. Sanitary Facilities: ° k) <br /> Ty e fs ruction No. Bathrooms /• • • Z Z ° <br /> 1. Work p No. Bedrooms / o ° <br /> New Building . . . . . . e . . . ft. x . . ✓�ft. Septic Tank Size Gals. . . <br /> Addition Height . . . . . Stories . . . . . . . . . . . <br /> \ <br /> Sanitary Area . . . . . . . . . . . . . . . . . . . 7a.Absorption Field Site: <br /> Filling Soil Type . . . . . . . . . . . . . . . . . . ° <br /> Moving . . . . . . 5. Permits Required Slope • . • . . • • • • • • • • • • • • • • • a <br /> Grading . . . . . . Subdivision Perc. Rate . . . . . . . . . . . . . . . . . <br /> Mobile Home . . . . . . Sanitary Dry Well . . . . . . m <br /> Privy g Seepage Trench j <br /> Well . . . . . . Well Privy . . . . . . <br /> Subdivision . . . . . . Other (Specify) . . . . . . Seepage Bed . . . . . . :lam <br /> Conditional \ <br /> 2. Classification Land Use . . . . . . <br /> Zoning Dist. � n o <br /> 6. Use (describe exactly 1 -fam. <br /> 3. Lot Size home, motel,etc.) FOR COMMERCIAL USE :—} ° <br /> o <br /> /' f�t.x . . . . . . . . ft. � Plans Submitted . . . . . . , <br /> b !. .Q. . . . . . sq.ft. Plans Approved ' <br /> . . . pp ; <br /> --- ------------------------------------------------------------ <br /> iC\ 1 <br /> Fig. A. Location of proposed structures and <br /> existing structures, well, sewage sys- <br /> tems, roads, etc., should be sketched <br /> n �•7 —� in Fig. A. Include road setback, side : s <br /> and back yard dimension and location i� o <br /> and setback from all bodies of water. (�M, <br /> If property is located at a highway in- <br /> tersection, show the intersecting high- <br /> ways and the setbacks required along <br /> 0p them and at the intersection. <br /> r PERMIT FEES <br /> ` lop Subdivision $15.00' m <br /> 7r <br /> Land Use . . . . . . . . . . . 1.00 <br /> . . . "� 5.00 <br /> itar . . . . . �v ' • B (\ <br /> A'j y b�'lfis!Y�, . . . . . . . . . . . 5.00 <br /> Septic Tank . . . . . . . . • 10.00 r' <br /> Combination Building, Sanitary <br /> and Well . . . . . . . . 15.00 <br /> C? Privy . . . . . . . . . . . . 5.00 <br /> �Ur <br /> Signature of Owner r A Y0t e egd� istrator �.. <br /> InspectionDate ................................................ Inspector ................................................................................................ <br /> Remarks ............................................................................................................................................................ <br /> ................................................................................................................................................................................................ <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 />