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Burnett Cour•ty Office of Zoning Administrator o Z <br /> m m y O O <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT �• 3 r <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a <br /> V <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, t ,, <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- CL W <br /> lags of the State of Wisconsin. ' :� O <br /> /.x.41-SS. . . C����ij-•�.�. . . . . . . . . . . . . . . . . . . . <br /> 3 d <br /> Owner or Agent!(please print) Contractor or Surveyor <br /> Address Address a <br /> � r <br /> P. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Phone <br /> mlll <br /> umber Well Driller <br /> Address Address ` ' m O <br /> O <br /> _ V n <br /> <5 3 to o <br /> Phone Phone o <br /> o <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities o -0 <br /> Type of Construction No. Bathrooms . . o Z 0 <br /> 1. WorkDishwasher /. . . . o <br /> New Building . . Size . . . . . ft. x . . . . . . ft. Garbage Grinder . . . . . . <br /> Addition Height . . . . . Stories . . . . . . Autom. Laundry (. . . . :� <br /> Sanitary . . Area . . . . . . . . . . . . . . . . . . . No. Bedroomsu m : <br /> Alterations . . . . . . Waste Disposal System C . . , o <br /> Moving . . . . . . 5. Permits Required Septic Tank Size Gals. <br /> Wrecking . . . . . . Subdivision . . . . . . Absorption Field Site ) T : <br /> Mobile Home . . . . . . Sanitary Soil Type <br /> Privy . . . . . . Building Slope . . .?<! . . . . . . . . . . . . y> <br /> Well x. . . Well x . . Perc. Rate . . 3. . . . . . . . . . . . ; <br /> Subdivision Other (Specify) Dry Well (�( <br /> Conditional . . . . . . Seepage Trench <br /> 2. Classification �/ Land . . . . . . Privy . . . . . . o- 2 <br /> Zoning Dist. Seepage Bed . . . . . . <br /> 6. Use (describe exactly, 1 -fam. N' <br /> 3. Lot Size home, motel,etc.) FOR COMMERCIAL USE <br /> ft. x . . . . . . . . ft. Plans Submitted I ..N <br /> . . . . . . . . . . . . . . . . . . sq. ft. Plans Approved . . . . . . <br /> Fig. A. Location of proposed structures and <br /> existing structures, well, sewage sys- <br /> tems, roads, etc., should he sketched �1 <br /> in Fig. A. Include road setback, side <br /> and back yard dimension and location <br /> and setback from all bodies of water. <br /> If property is located at a highway in- <br /> Ltersection, show the intersecting high- ' :C <br /> ways and the setbacks required along <br /> them and at the intersection. <br /> PERMIT FEES <br /> Subdivision . . . . . . . $15.00j D <br /> Land Use . . . . . . . . . . . 1.00 <br /> Building . . . . . . 5.00 r ^ <br /> Sanitary 4+$9� V, <br /> Well . . . . . . <br /> Septic Tank �Q.00 <br /> Combination Building, Sanitar <br /> and Well . . . . . . . . 15.00 <br /> ................................................... ......................�...>..... . .. ..:� .. L:4 <br /> ................................ <br /> ignature of Owner or Agent Date Z istrator <br /> — _ 2r.9 <br /> / <br /> Inspection Date . ....../. / . .. Inspector ... ...........................4.......................................................... <br /> 9.......... <br /> Remarks .. / .t�'L:..�. <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 />