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Burnett County Office of Zoning,Administrator nq Ca nI o H z <br /> CD CD m 0 \o <br /> APPLICATION FOR SANITARY — LAND USE — BUIL:DING PERMIT -a - �- <br /> TO THEE ZONING ADMINISTRATOR: The undersigned hereby makes application for a -I = :-, o <br /> P.,rmit for the work described and located as shown herein. The undersigned agrees that all o y <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, x- CD ' .„...„ <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- -v °- <br /> ,Z <br /> CD of the State of Wisconsin. � o_ ..%(") O <br /> / �Q 3 <br /> h N Y r� 4 .e .-4m 4, <br /> Owner or Agent (please print) Contractor or Surveyor N , fD <br /> �.�,,rtb JI TT ( SC , rNg9 ) CD <br /> Address Address N1 � <br /> a 1 <br /> c. <br /> m <br /> Phone % Phone <br /> tl_eslil...),...r..4,_ <br /> Plu ber Well Driller , Q <br /> t ' 7 <br /> 0 <br /> Address Address <br /> 0 .c <br /> 0 o <br /> • <br /> Phone Phone 'y o m A <br /> �CD 0+ . <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: -° <br /> Type of Construction No. Bathrooms o z a <br /> 1. Work No. Bedrooms �`�� ° � <br /> New Building Size ft. x ft. Septic Tank Size Gals. -z... <br /> Addition Height Stories 1 F <br /> Sanitary �/ Area 7a.Absorption Field Site: <br /> VI <br /> Filling Soil Type o <br /> Slope <br /> h <br /> Moving 5. Permits Required P <br /> Grading SubdivisionPerc. Rate , <br /> Mobile Home Sanitary .f Dry Well m m <br /> Privy Building Seepage Trench CD CD r <br /> Well Well Privy • <br /> ' �. . to no <br /> Subdivision Other (Specify) Seepage Bed /J.! /. / o <br /> Conditional 0 , cn N <br /> 2. Classification Land Use 0- 0 <br /> Zoning Dist. �°• o• <br /> 6. Use (describe exactly, 1 -fam. \ r1 <br /> 3. Lot Size home, motel,etc.) FOR COMMERCIAL. Sesi <br /> ft. x ft. Plans Submitted p I <br /> sq. ft. Plans Approved <br /> Fig. A. Location of proposed structures and <br /> LL -f- -V. -Io <br /> / < / N �P _ existing structures, well, sewage sys- o <br /> 7 <br /> tems, roads, etc., should be sketched <br /> N in Fig. A. Include road setback, side F3 s <br /> o X' ?J L <br /> 11'.. ' a--��- Xd and back yard dimension and location ) <br /> and setback from all bodies of water. ,w <br /> If property is located at a highway in- <br /> 4.) <br /> tersection, show the intersecting high- �Q <br /> \��f 4) ways and the setbacks required along <br /> them and at the intersection. I <br /> PERMIT FEES 91 <br /> mz <br /> D <br /> t'o'e Subdivision $ CD <br /> V ‘ Land Use /6.00 ) <br /> 3 LBuilding i:� <br /> Sanitary 15‘tWell ' <br /> 8 <br /> Septic Tank 10.00 <br /> Combination Building, Sanitary <br /> and Well 1$6 <br /> Privy 5.00 <br /> k^vr--/ - <br /> 49/7 9 4, / ' ig - -,/t(ig6.-/(1„ <br /> of Owner or ;gent Dat con4hSignatureinistrator <br /> Inspection Date Inspector <br /> Remarks <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 />