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Burner! County Office of Zoning Administrator N o Z <br /> m m y ° ° <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT �. 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a 0 <br /> Permit for the work described and located as shown herein. The undersigned agrees that all H <br /> work shall be done in accordance with the requirements of thex,County Zoning Ordinance, V,1 <br /> Sanitation Code, and with all other applicable County Ordinanes a the laws anti v <br /> Wi a <br /> regu- <br /> lations of the State of consin. \` `� a 0 <br /> 3 i! <br /> G m <br /> �!�G . } m.aV . .4. itt0.,11 . v?"\ . . . .(�. . <br /> Owner o Agent ( lease�rint) Contractor or Surveyyo�r E S.pn,•.ap�o ? I � <br /> q. t <br /> i� STAR Kd,uY g�N a9QA c f\ <br /> dress •1\` - /� -�Ad L`ess <br /> e� V N lqO V\ <br /> � <br /> . . . . .°1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> PhpnQ� r Z3 Phone .rte/�1 <br /> . . . 1. . . .1.�. J. . . . . . . . . . . . ./. . . . . . . . . . ��//CQ�'�I {.4/.��.�. . . . . . . . <br /> Plumber Well Drille� <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> o <br /> Address Address L <br /> 0 0 3 <br /> o <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> f <br /> Phone Phone 0 <br /> DESC R IPTION 4. Building Details 7. Sanitary Facilities: 1 -O <br /> Ty,�,yg o truction No. Bathrooms 1`j o 0 <br /> 1. Work �/ . .C.j. . . . l�-C}wye--. . . . No. Bedrooms � . . ° <br /> New Building . X. . Size :.0-y it. x 3. . . .eft. Septic Tank Size Gals. . . . . . . <br /> Addition . . . . . . Height .c .y. Stone k. . ' <br /> Sanitary . . . . . . Area �3 r 7a.Absor tion Field Site: :w Q <br /> Filling . . . . . . . . Soil Type . . . . . . . . . . . . . . . . . . :\ ° <br /> Moving . . . . . . 5. Permits Required Slope . . . . . . . . . . . . . . . . . . . . :� .a <br /> Grading . . . . . . Subdivision . , . . . . Perc. Rate . . . . . . . . . . . . . . . . . �:w <br /> Mobile Home . . . . . . Sanitary Dry Well . . . . . . O p <br /> Privy . . . . . . Building . .k, . . Seepage Trench . . . . . . <br /> Well Well Privy . . . . . . <br /> . . . . . . . . . . . v <br /> Subdivision Other (Specify) . . . . . . Seepage Bed . . . . . . <br /> Conditional <br /> 2. Classification Land Use . . . . . . I :tea <br /> Zoning Dist. �uX. Q o <br /> 1r <br /> K+ 6. Use (describe exactly, 1 -fam. �dvctr.tiw�V�,p v✓t�- � `\ <br /> 3. Lot Size �••y� home, motel, etc.) FOR COMMERCIAL USE F 0 7� <br /> . . . ft. x ft. Plans Submitted . . . . . . CC• ,,II <br /> . . . . . sq. ft. Plans Approved <br /> -----, ----------------------------------------------------- -------- <br /> Fig. <br /> ---------------------------------------------------- <br /> Fig. A. Location of proposed structures and <br /> existing structures, well, sewage sys- o <br /> tems, roads, etc., should be sketched <br /> �t1 in Fig. A. Include road setback, side p <br /> and back yard dimension and location :C <br /> and setback from all bodies of water. <br /> If property is located at a highway in- ^i`C <br /> tersection, show the intersecting high- <br /> \ ways and the setbacks required along <br /> them and at the intersection. <br /> PERMIT FEES <br /> Subdivision..... $25.00 + $2.00 per lot. <br /> �• lS� Land Use................. ............... $10.00 t\ <br /> S'y' � �- uildin . .............. 5........ -X6...8 <br /> Sanitary .................................. 20.00 :Q <br /> Well ........................................�S 10.00 Septic Tank ............................ 10.00 �+ <br /> b <br /> �S <br /> \a Privy ....................................... 5.00 � o <br /> I6/ < <br /> .v .. p'e o 41. 1PC ........ .......... P. 2�'�5.............. ind11 ..�.J. ................. <br /> �� <br /> ll <br /> lure o wrier or Ag ent L/ Date Zonin A mistrator <br /> Inspection Date .........'.t�...l.�'z3.1 Inspector ...._. <br /> ......................................................................................... <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 dispo%f I 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 revoke,') if misreprl;sentation 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 />