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Burnett County Office of Zoning Administrator �.� 4) <br /> 0 0 <br /> APPLICATION FOR SANITARY — LAND USE BUILDING PERMIT �, 3 <br /> 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application fora <br /> Permit for the work described and located as shown herein. The undersigned agrees that all d <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, 77 <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- - a <br /> lations of the State of Wisconsin. t 0 js 1 p <br /> ' ,1"! ?R � <br /> Owner or Agent (please print) Contractor or Surveyor H '/ NA <br /> I <br /> . . . . _ S'T. . . . . . . . . . . . . . . .�7�9t�' ���r 'f. . . ?!t... . . . . . . . . . Q `� PAddress Address <br /> �� ��o <br /> Phone Phone ( ' <br /> ahs:r. . . . . . . . . . . . . . . . . . . . . . . . . . . . Are�- K . . . . . . . . . . . <br /> Plumber Well Driller , _ <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Address Address m G) ;C <br /> . o <br /> Phone Phone H 0 <br /> o <br /> o <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: <br /> Type of Construction No. Bathrooms o z 0 <br /> 1. Work �s27 .. No. Bedrooms ° <br /> New Building x . Size .2C/, ft. x . . ft. Septic Tank Size Gals. *750 <br /> Addition . . . Height . . . Stories . I. . . t <br /> : c <br /> Sanitary .. .)S,. Area . . . . . . (.00e . . . . . 7a.Absorption Field Site: ` c ' <br /> Filling . . . . . . Soil Type . . . .64. . . . . �: o <br /> Moving . . . . . . 5. Permits Required Slope . . . . <br /> Grading . . . . . . Subdivision . . . . . . Perc. Rate . . . . . . . .J. . . . . . . = <br /> Mobile Home . . .. . . Sanitary ', Dry Well m - <br /> Privy . . . . Building , , ,X,, Seepage Trench . . . . . . <br /> Well Well , . Privy . . . . . . 76 :v <br /> Subdivision . . . . . . Other (Specify) . . . . . . Seepage Bed X. o <br /> Conditional j ` 3:3' Cn y <br /> 2. Classificationt Land Use . . . . . . CL <br /> Zoning Dist. `pV.l.(.J o <br /> 6. Use (describe exactly1 -fam. H' <br /> 3. Lot Size 'Wo-m—el motel,etc.) FOR COMMERCIAL USE ° <br /> x ft. Plans Submitted `f <br /> sq.ft. Plans Approved 1q <br /> Fig. A. Location of proposed structures andkJ}j <br /> existing structures, well, sewage sys- <br /> tems, roads, etc., should be sketchedv :Ah <br /> in Fig. A. Include road setback, side <br /> 23' and back yard dimension and location l� o <br /> �. and setback from all bodies of water. :k <br /> If property is located at a highway in- y <br /> /h 83t tersection, show the intersecting high- <br /> 4� ways and the setbacks required along :(\A <br /> g them and at the intersection. <br /> PERMIT FEES <br /> r r Subdivision . . . . . . . . . $15.00 :(A :� m <br /> Land Use . . . . . . . . . . . 1.00 ;C <br /> Building . . . . . . . . . . . 5.00 :t3) <br /> Sanitary . . . . . . . . . . 10.00 <br /> fpr Well . . . . . . . 5.00 0 [_ <br /> Septic Tank . . . . . . . . . 00 (� <br /> Combination Building, Sanitary <br /> and Well . . . . . . 15.00 <br /> V w Privy . . . . . . . . . . . . 5.00 <br /> Q c <br /> C ✓2 2e <br /> ..... . ......... ... ........................ . . . <br /> Signature of Owner or Age <br /> n Date Zonin Adminis or <br /> Inspection Date ....... /... 11�7.Q. Inspector 2. <br /> ...f).. <br /> ` . <br /> 0 <br /> Remarks ........................... .. <br /> ...E`5............. .. ........... .... ............................................................................................. <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 />