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Burnett County Office of Zoning Administrator cn �`> z; <br /> m m m ° ° <br /> APPLICATION FOR SANITARY — LANE) USE — BUILDING PERMIT °. 3 <br /> n � <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 : 1 <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, \j <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- °- ` ^ <br /> lations of the State of Wisconsin a ;4i O <br /> / {�/�/J m <br /> C �l, 9r Y. s . L .4 .�I e ! � 4J. .� C'j'.f- C „uJ�3 <br /> . . . . . as . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Owner Jor Agent((�please{7print) Contractor or Surveyor H :H <br /> Address Address <br /> . Syy � <br /> Phone Phone <br /> . . <br /> Plumber Well Driller <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> . . . . . . . . . . . . . . . . . . . . . . —. <br /> n <br /> Address Address 0 o : s <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Phone Phone 0 <br /> m ° <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: , h <br /> Type of Construction No. Bathrooms -0 - • o Z °° <br /> 1. Work f. r . .:1'+1. . . . . . . No. Bedrooms Z • ° <br /> New Building . . . . . . Size ..R4. ft. x . . . ft. Septic Tank Size Gals. . . ?� <br /> Addition Height . . . . . Stories . . . . . . <br /> Sanitary . . . . . . . . . .. . . . . . . . . . 7a.Absorption Field Site: O <br /> Filling . . . . . . Soil Type . . . . . . . . . . . . . . . . . . �` (� o <br /> Moving . . . . . . 5. Permits Required Slope • • • • • • • . • • • • • • • • • • • • v W <br /> Grading . . . . . . Subdivision Perc. Rate . . . . . . . . . . . . . . . . . <br /> Mobile Home . . . . . . Sanitary t✓ Dry Well m m <br /> Privy / Building ✓. Seepage Trench . . . . . . fA <br /> m m <br /> Well /. Well J Privy p . <br /> Subdivision Other (Specify) . . . . . . Seepage Bed . �a <br /> �tConditional . . . . . . Cn Cn <br /> 2. Classification Land Use . . . . . . a 0 <br /> Zoning Dist. . . . . . . ° <br /> 6. Use (describe exactl( 1 -fam. ° <br /> 3. Lot Size home, motel, etc.) FOR COMMERCIAL USE ° <br /> ° <br /> . . . . . ft. x . . . . . . . . ft. Plans Submitted . . . . . . <br /> 'd. !G A 5? 4 ."r. . sq. ft. -------------- Plans Approved :w <br /> -------- ———————————————— <br /> Fig. A. Location of proposed structures and l <br /> %a existing structures, well, sewage sys- .o <br /> tems, roads, etc., should be sketched <br /> \d in Fig. A. Include road setback, side _; s <br /> and back yard dimension and location a <br /> and setback from all bodies of water. <br /> If property is located at a highway in- <br /> tersection, show the intersecting high- <br /> OI ways and the setbacks required along y• <br /> (� .3 them and at the intersection. <br /> D <br /> 1,' �n PERMIT FEES <br /> Subdivision . . . . . . . . . $1-SM$ <br /> Land Use . . . . . . . . .;o /d'.00 Building . . . . . . . . . . . \ <br /> Sanitary <br /> y" <br /> Well . . � <br /> Septic Tank . . . . . . . . . <br /> 10.00 <br /> Combination Building, Sanitary r <br /> and Well . . . . . . . . 4�_ <br /> Privy . . . . . . . . . . . . 5.00 <br /> 7 <br /> �{. P""".:9..................................9................ Y/. ./. `j.... ....... .. g .......................... <br /> Si nature of Owner or Agent D to °.. dministrator <br /> Inspection Date . .. � /.^..7�/... ........... Inspector ... .L :_.1*.7_;: J...e!57 sib/ �............................... <br /> Remarks .........�......�c!....1 4: Y....t z E� ........................ <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 />