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Burnett County — -Office of Zoning Administrator�y(� p� o / <br /> APPLICATION FOR SANITARY — LAND.USE BUILDING PERMIT '. 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a o _sem <br /> Permit for the work described and located as shown herein. The undersigned agrees that all F <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance. °n i� ,yl <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and ragu o. i r V <br /> lations of the State of Wisconsin. <br /> K r may— 3 a. ! J :A o <br /> Q.L'.V l. � l.a. . . .t.1. 0. R'�r R4SL. . . . M .0 �,l) 7h / �• . . . . . . . . . . . . <br /> Owner or Agent (please print) Contractor or Surveyor <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> / (� n <br /> . F.�. y. .Q. . .�. . . . . 711 u.e�. . . . . . <br /> Address Address a <br /> nn' SS(0 c <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Phonen 1 Phone <br /> V1 .l 1. A ISlns. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Plumber � Well Driller <br /> V o <br /> t <br /> Address Address <br /> Phone Phone � •�^ o irt• I <br /> m <br /> n _ <br /> 0 <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: <br /> Typ��.RPf Construction No. Bathrooms o Z c <br /> 1. Work I / .C-. !'.V.!^'`,�,�,. . . . . . No. Bedrooms . . .°' 0 NI <br /> New Building . . . .Y Size ft. x .3.SZ. ft. Septic Tank Size Gals. <br /> Addition Height . . . . . Stories . . . . . . <br /> Sanitary . . LI-1Area . . . . . . . . . . . . . . . . . . . Za.Absorption Field Site: i , i X i •, <br /> Filling . . . . . . Soil Type . . . . . ".� . . . . o <br /> Moving . . . . . . 5. Permits Required Slope . . .. . . . . . . . . . . . i <br /> Grading . . . . .. Subdivision <br /> Part. Ratee . . . . . . . . . . . . . . . . . <br /> Mobile Home . . . . . . Sanitary Dry Well . . . . . . <br /> Privy / Building L /� Seepage Trench <br /> Well . .L Well . .(J Privy o, E I <br /> Subdivision Other (Specify) . . . . . . Seepage Bed <br /> /� Conditional V I c n i <br /> 2. Classification PVIu Land Use . . . . . . j I c, <br /> p <br /> Zoning Dist. . . . <br /> 3. Lot Size <br /> 6. Use (describe exactly 7 -tarn. <br /> home, motel,etc.) FOR COMMERCIAL USE <br /> ft. z . . . . . , ft Plans Submitted <br /> sq. f . Plans Approved .. . . . . �j <br /> ______________________ ______________ <br /> Fig. A. <br /> Location of proposed structures and <br /> existing structures, well, sewage sys <br /> terns, roads, etc., should be sketched <br /> Ttex <br /> ` A. Include road setback, side <br /> andback yard dimension and location' and setback from all bodies of water.9 If property is located at a highway in <br /> 7 trisection, show the intersecting high <br /> 30 ways and the setbacks required along <br /> them and at the intersection. '� \ <br /> D �t v Y <br /> WNI a (to <br /> PERMIT FEES pI <br /> \._ r Subdivision $15.00 <br /> N � 1�5 Land Use . 1.00 <br /> t�� Building � � � � � � � � � � � 5.00 <br /> Sanitary . . 10.00E <br /> ",a <br /> Well 5 0 <br /> Septic Tank 10.0 �I <br /> Combination Building, Sanitary <br /> and Well . . . . . . . 15.0 <br /> Privy . . . . . . . . . . . . 5.00 <br /> 11-12-77 4all <br /> Signature of Owner or Agent Date Z— ing A in istrator <br /> Inspection Date J/11$"-...x....7� ... Inspector .. AL1;¢lPi2sP!.(1� �5'4.e................... .... <br /> ...._... <br /> ............. Reor arks <br /> ..................... ..... ................ ..._ <br /> ......... ... .. �.�. .ter` ....... ..............:.... : : :. : ::. ::: : :' <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 Adm inistrator! <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED, <br /> I <br />