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Burnett County Office of Zoning Administrator N 0 --1 Z <br /> W o 0 <br /> APPLICATION 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 <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. <br /> a 0 <br /> s. .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Owner or Agent (please print) Contractor or Surveyor N <br /> Address Address o :` <br /> Phone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Phone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> . . . . . . . . <br /> Plumber Well Driller y <br /> Address Address0 o <br /> ` <br /> y. 6 .- .7. 3. . . . . . . . . . . . . <br /> `� ' U <br /> Phone Phone N r <br /> n o <br /> 0 <br /> m 0 0 <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: ° <br /> Ty p L,c�t}'�j No. Bathrooms o Z 00 <br /> 1. Work � 1.!!Y. . . . . No. Bedrooms o m p <br /> New Building . . . . . . Size . . . . . ft. x . . . . . . ft. Septic Tank Size Gals. '750-6,4i_ <br /> Addition Height . . . . . Stories . . . . . . :k'� :\ <br /> Sanitary Area . . . . . . . . . . . . . . . . . 7a.Absorption Field Site: :Nr� :�. <br /> Filling . . . . . . Soil Type . . . . . . \ :O o <br /> Moving . . . . . . 5. Permits Required Slope <br /> . . . . . . . . . . <br /> Grading . . . . . . Subdivision Perc. Rate . . .%. . . . . . . . . . . . . <br /> Mobile Home A.Sanitary , • Dry Well M :A <br /> Privy . . . . . . Building Seepage Trench . . . . . . D `TS <br /> Well . . . . . . Well Privy f <br /> Subdivision Other (Specify) . . . . . . Seepage Bed �A+ <br /> izs <br /> Conditional . . . . . . / ° to N <br /> 2. Classification Land Use ` o- <br /> Zoning Dist. AW" ¢ ° <br /> 151 6. Use (describe exactly, 1 -fam. N' ° <br /> 3. Lot Size home, motel, etc.) FOR COMMERCIAL USE ° <br /> . . . . . . . . . ft. x . . . . . . . . ft. / r,Q J �j�/j,� Plans Submitted . . . . . . <br /> . . . . . . . . . . . . . . . . . . sq. ft. / / " "` z "rC Plans Approved <br /> --- <br /> Fig. A. Location of proposed structures and <br /> --�-- _J_ existing structures, well, sewage sys- � o <br /> tems, roads, etc., should be sketched <br /> ISE <br /> in Fig. A. Include road setback, side <br /> — — and back yard dimension and location a <br /> and setback from all bodies of water. <br /> ♦ u If property is located at a highway in- <br /> S)tt'TiC Tf1Nk tersection, show the intersecting high- <br /> Or <br /> igh- <br /> seEf'�6E OFD ways and the setbacks required alongAl- <br /> \Yl <br /> /z rX Ay <br /> �� / O 5vs �✓r �hl(�Hat}teln and at the intersection. �* <br /> tts� PERMIT FEES <br /> — — t Subdivision..... $25.00 + $2.00 per lot. <br /> (� >(O II--JI• Land Use..............................0.. $10.00 <br /> Q — — B ii ding_................................... 10-00 <br /> �. <br /> �( ri I >�D an6 itar 35.00 <br /> er �FNT Well <br /> .................................. 10.00 <br /> >Ib, YVE44 Privy ...................................0... 5.00 <br /> c-� �,OT LI NF, <br /> �� <br /> ............. . . ........ ...:........... . . . ........ ................ aG .................................. <br /> Signature of Owner or Agent v Date Zoning Administrator <br /> InspectionDate ..............................................0. 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 />