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1toBurnett County Office of Zoning Administrator ( `fo o -i <br /> cD CD y 0 0 <br /> • APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT -0 - <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a H - o• • <br /> Permit for the work described and located as shown herein. The undersigned agrees that all ct, H <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, m . r <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- ° �7� <br /> lations of the State of Wisconsin. /� l 3 a O <br /> . .�•44(,l&r'r� GNB in 15aCw� Ill"r,� ;�,'. . . .eG?''?5/ �. co <br /> `° 1� CD <br /> Owner or Agent (please print) Contractor or Surveyor v> <br /> "�' :, . <br /> .-.- .6 ell . .4o ei, .51(--"7/ s A ed 4 4e.._. <br /> . . .,. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . co <br /> ._ <br /> t !N., : <br /> Address Address a L j <br /> 446 7(0° <br /> 7 . 139 .;): <br /> Phone Phone <br /> • <br /> Plumber Well Driller <br /> Rr. ELL ,tA/cr \ 0 <br /> Address Address m o <br /> & 36 ' - >46 Ni <br /> o <br /> Phone Phone ,T y m <br /> n 0 <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: <br /> Type of Co ruction No. Bathrooms o z oo <br /> Com <br /> ruction <br /> Work W O?CQ . fr �f.�t.e- No. Bedrooms a o CD <br /> 0 <br /> New Building Size 4. ft. x .. ,. ft. Septic Tank Size Gals. .7SiP. , O ..Z- <br /> Addition <br /> . <br /> Addition Height!. Stories . .i . <br /> Sanitary �! Area . . . .w.. J. . .-f.f. 7a.Absorption Field Site: <br /> Filling Soil Type /��� � 0 <br /> o <br /> Moving 5. Permits RequiredSlopey\ <br /> Grading Subdivision Perc. Rate �V • <br /> Mobile Home Sanitary .i; Dry Well71 �� <br /> PrivyBuilding Seepage Trench m `D <br /> Well Well Privy to fi) <br /> Subdivision Other (Specify) Seepage Bed xc <br /> Conditional G cN N <br /> 2. Classification Land Use ' 6CD <br /> Zoning Dist. °- o <br /> 6. Use (describe exactly, 1 -fam. H' <br /> 3. Lot Size home, motel,etc.) FOR COMMERCIAL USE o )l1 <br /> / .t . . . ft. x ft. ,r;��4Se.Y.1L Plans Submitted <br /> (j��/ . . Cte 5. . . sq. ft. CAA;A/ Plans AApproved <br /> ��``'' Fig. A. Location of proposed structures and <br /> existing structures, well, sewage sys- — o <br /> ��� <br /> tems, roads, etc., should be sketched --- n <br /> in Fig. A. Include road setback, side 3 <br /> and back yard dimension and location -5. <br /> and setback from all bodies of water. 1 <br /> If property is located at a highway in- k.) <br /> tersection, show the intersecting high- .7- V <br /> ways and the setbacks required along . <br /> ..%,,4 <br /> and at the intersection. l <br /> \ PERMIT FEES .)--1 <br /> CD <br /> UZI <br /> CA8`N Subdivision $15.00 fD <br /> Land Use 1.00 i � <br /> Building 5.00 1/i <br /> Sanitary 10.00 <br /> �` Well 5.00 <br /> ,1 Septic Tank �, <br /> 'T .rcQ II <br /> Combination Building, Sanitary <br /> and Well 15.00 <br /> et,/ B. <br /> Privy 5.00 <br /> )4C)//7-- 77 4111P i ' , 0-deLid <br /> .... - .......Signature Owner or gent Date_, Zo 'ng 6nistrator <br /> Inspection Date 'e'n Inspector l/"` g �-'•�tr-E.$ `•:--4- <br /> Remarks . ...'�, e..c - --f <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 />