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�c>> <br /> Burnett County Office of Zoning Administratrat or � o � z <br /> APPLICATION FOR SANITARY — LAND U$E — BUILDING PERMIT o 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a _ o <br /> Permit for the work described and located as shown herein. The undersigned agrees that all µ :� <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, n + <br /> Sanitation Code' and with all other applicable County Ordinances and the laws and regu- _ V <br /> lations of^the State of Wisconsin. O <br /> 3 F <br /> ''//> /1q�Jil 'Sc% <br /> /�A.U,ec'� ..P. /7cc rr.c It . . . . . . N V1 <br /> Owner or Agent (please print) Contractor or Surveyor <br /> %X. 3 �y. . <G•. �. c2 , . . . . . . . . . . . . . <br /> Address Addresf d <br /> 3'>!9. .5:`l.!9 c. n. . . . . . . . . - e <br /> . . . . . . . . <br /> Phone <br /> Phone 1 <br /> J <br /> Plumber Well Driller : <br /> f � i [� <br /> 1� . . . . . . . . . . . . . . . . . . . . . . . . <br /> Address Address <br /> . . ` ` . . . <br /> Phone Phone \I�(1 o <br /> w o <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: <br /> Type f Construction No. Bathrooms y Z z <br /> pp o 0 0 <br /> 1. Work . . .),DO ye. .aZX .ka�(s No. Bedrooms ... . . . <br /> New Building . h. . . Size . .�L zft. x .,� f Septic Tank Size Gals. <br /> Addition . . . . . . Height ./. Stories . P:- . . . . . . <br /> Sanitary . . . . . . Area . . / O C' .$ f:r. 7a.Absorption Field Site:Soil Type . . . . <br /> r- <br /> Filling . . . . . . <br /> Slope <br /> Moving . . . . . . 5. Permits Required 'ff <br /> Grading . . . . . . Subdivision Perc. Rate . . . . . . . . . . .k'. . . . . :1 <br /> Mobile Home . . . . . . Sanitary �-^ Dry Well . . . . . . <br /> Privy . . . . . . Building r� Seepage Trench . . . . . . <br /> m <br /> (/ Privy <br /> Suebdivision . . . . . . Othler (Specify) . . . . . . Seepage Bed4:X. <br /> Conditional . . . . . . C'ff'y r' c m <br /> 2. Classification Land Use .t✓. , Q <br /> a <br /> 0 <br /> Zoning Dist. . . . . . . <br /> 6. Use (describe exactly, 1 -fam. <br /> 3. Lot Size .7< home, motel,etc.) FOR COMMERCIAL USE , <br /> . ..-< . . .pp. . ft. x . . . <br /> . . ft. Plans Submitted <br /> .: <br /> (v B0`70 :111111101! . . . . . . sq. it. J-/"tH/`'r'll geMc- Plans Approved . . . . . . <br /> ----------- ----- / ------ ----- <br /> Fig. A. Location of proposed struCtL res and i I i(. .� <br /> / e. /f•�r` � %y37 existing structures, well, sew ge sys- <br /> tems, roads, etc., should be ketched <br /> / in Fig. A. Include road setback, side ick s <br /> 1t k r4{ r z L, and back yard dimension and location I o <br /> and setback from all bodies of water. 'Qr <br /> e <br /> 1 If property is located at a highway in- <br /> / <br /> n- <br /> _y/os tersection, show the intersecting high- <br /> T ways and the setbacks required along <br /> them and at the intersection. k. <br /> .(J <br /> k <br /> ^ . / PERMIT FEES <br /> Subdivision . . . . . . . $1b!�9F <br /> Land Use . . . . . . . . , <br /> Building . . . . . . . . . <br /> Sanitary . . . . . Q t@'r99 � <br /> Well 1. D 5c9B <br /> r Septic Tank . . . . . . . 10.00 <br /> 1 Combination Building, Sanitary <br /> O— and Well . . . . . . 1&gm <br /> f4 A,k F`t-id � Privy . . . . . . . . . . 5.00 <br /> Cl .a o _ K <br /> :... 7�ay�C�// � ... ........L ..c3uG....9 ` . .............................. <br /> Si ature of n e r or ent U, Date Zoni d in istrator <br /> Ins e—'ctT6fr._' te .� .. ...`.. ...Inspector ..... ..�:F... .:�� ... �'....................... <br /> arks (�/.l .�G.'�..}-.�R..Y.-"..:f.` ...._ /G�-K.�V... ..�?�"L......�`.r ...... ......•........................ <br /> ................................................................................................................................................................................................ <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures in jolving 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 plu nbing or start any build- <br /> ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the inf rmation conveyed here- <br /> with is found to exist. Changes in plans or specifications shall not be made without approval of tl e Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE ND APPROVED. <br />