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Burnett County Office of Zoning Administrato ?! d Z <br /> a o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT °. 3 <br /> ° rr <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 m •:'� t " <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 St of Wisconsin. p <br /> :� . <br /> 3 d w .�' <br /> I.I4.' ./ . . . . . . /.S!.fd. . . . . . . . . . . . . . / t� 4 nS l�jr , ld . . . . . . . . . . . . . . " <br /> Owner or Agent (please print) Contractor or Surveyor <br /> IF'/IufY a 4 <br /> Address Address a <br /> L40 0 0 a/ ' S-10 <br /> Fry . . . . . . . . . . . . . . . . . . . � <br /> Ph�onet. . . . . . . . . . . . .; . . . . . . . . . . . . . . .Phone . . . . . . . . . . . . ` <br /> lfod. . .1A0. .ktr . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . �' <br /> Plumber P . . . . . . . . . . . <br /> Well Driller �\ `\( I <br /> . . . . . . . . . . . . . . . . . . . . . . . . . .ddre. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Address Ass o , <br /> _. _3(2) <br /> Phone . . ,O.f. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OQ�, _ <br /> Phone Phone I »J <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: ' ' <br /> Type of Construction No. Bathrooms o Z �i <br /> ci <br /> 1. Work /j . . . F—./`.a.":c.. . . . . . . . . . No. Bedrooms . . . .. .. f). o <br /> New Building . . . . . . Size A4. ft. x : . k. ft. Septic Tank Size Gals. <br /> Addition Height . . . . . Stories . . . . . . .-S'. <br /> Sanitary Area . . . . . . . . . . . . . . . . . . . 7a.Absorption Field Site: <br /> "v1� QP <br /> Filling . . . . . . Soil <br /> Type <br /> . . . . . . . . . . . . . . . . . . �jJ : A <br /> Moving . . . . . . 5. Permits Required . . . . . . . . . . . • . • . . . . ' <br /> Grading . . . . . . Subdivision - Perc. Rate 5 <br /> Mobile Home . . . . . . Sanitary Dry Well . . . . . . —� ,� ,� `'--`}4 <br /> Privy Building Seepage Trench . . . . . . <br /> Well . .�� Well . , �-/ Privy / r.i� ffl :-.' <br /> 1,o <br /> Subdivision . . . . . . Other (Specify) . . . . . . Seepage Bed <br /> o " 1 .S' on (n <br /> Conditional _ ° <br /> 2. Classification R K.. ..( Land Use . . . . <br /> Zoning Dist. / ' . . . . . . o <br /> 6. Use (describe exactly, -fart's ' 0 <br /> 3. Lot Size home, motel, etc.) FOR COMMERCIAL USE ° <br /> . .((5.�. . ft. x . . 9.��. ft. Plans Submitted . . . . . . `-J i,q <br /> sq. ft. Plans Approved . . . . . . <br />-----------------------Fj--- <br /> SO '� ��9/�n, / - _ Af Location of proposed structures and <br /> �� .�/�U"�"" O �� � Z4z existing structures, well, sewage sys- <br /> tems, roads, etc., should be sketched <br /> in Fig. A. Include road setback, side T s <br /> I and back yard dimension and location <br /> and setback from all bodies of water. <br /> 7S If property is located at a highway in- <br /> tersection, show the intersecting high-60 <br /> ways and the setbacks required along <br /> them and at the intersection. <br /> PERMIT FEES 11j-U <br /> � I T . . . . . . . . <br /> Subdivision $15.00 m <br /> .�e Land Use . . . . . . . . . . . 1.00 <br /> (A' Building . . . . . . . . . . . 5.00 <br /> LF '�o�---�l dc.... Sanitary . . . . . . . . . . . 10.00 <br /> Well . . . . . . . . . . . 5.00 <br /> ��. Septic Tank <br /> nitar 0.00 <br /> Combination BuiI'd inSa <br /> g, <br /> and Well . . . . . 15.00 <br /> Privy . . . . . . . . . .00 <br /> .........�.... .. . .......................... �O . . .. <br /> S ignature��oof Owner or yAgent ate Z Ing in i s t r a t o r <br /> Inspection Date .:L.._l..L...�.../.../................... Inspector .C.r��zgs� C�� � <br /> J'' �a ................................... <br /> Remarks �d .b.e.TAJ7...........!...C..........1../..��Y...... r e.Y.?!7......................................................... <br /> .............................1.�.../., "C'.......... .........................................................._......................................... <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 />