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� t <br /> Burnett County Office of Zoning Administrator� I (N ( o z <br /> m m » o <br /> APPLICATION FOR SANITARY — LAND-USE — BUILDING PERMIT 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a o <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, F :� <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- jz ` r <br /> lations of the State of Wisconsin. 3 OV <br /> hti 1- r.�,l,. ) .� . . . . . . . . . . . . . . . . . . . . <br /> Owner or Agent (please print) Contractor or Surveyor 5 <br /> � � 4 r . . .t}t lly % b ii , Lv f S� o <br /> T. <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Address Address <br /> m _ <br /> Phone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Phone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> n l <br /> s. . . . . . . . . . . . <br /> Plumber Well Driller <br /> : <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ress. . . . <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Address Add (�/1 0 o .3� <br /> < <br /> :V o <br /> . .onee. ' . . . . . . . . . . . . . . . . . . . . . . . . . . . .Phone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Ph `�^ r <br /> � o <br /> � o <br /> D <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: <br /> Type of Construct-ion No. Bathrooms . • . /. . o o r. <br /> 1. Work . . -'�-.ICC.S.l .a. n . . . . . . No. Bedrooms /] <br /> New Building . . . . Size .;L,.`( ft. x .oZ ft. Septic Tank Size Gals <br /> Addition . . . . . ./ Height . . . . . Stories . . . . . . <br /> Sanitary . . �./. Area . . . . . . . . . . . . . . . . . . . 7a.Absorption Field Sj�. <br /> Filling . . . . . . Soil Type . . . . . . . . .y!4 . . . . . . o <br /> Moving . . . . . . 5. Permits Required Slope . . . . . . . . . . . . . /i. . . �\`y,\ <br /> Perc. Rate . . . . �' <br /> Grading . . . . . . Subdivision . . • ' -' <br /> Mobile Home y T T <br /> . . . . . Sanitary . , L:� Dry Welt . . . . . . <br /> Privy . . . . . . Building . , , _ . , Seepage Trench . . . . . . <br /> Well . . . . . . Well , , . , , , Privy ' <br /> . .p . <br /> Subdivision (Specify) . . . . . . Seepage Bed ./.1. Y o � 'T <br /> . . . . . Other (S 1 N <br /> Conditional . . . . . . C 0 <br /> 2. Classification Land Use . . . . . . <br /> Zoning Dist. . . . . . . .�,. o. 0 <br /> 0 <br /> 6. Use (describe exactl 1 -fames r <br /> 3. Lot Size home, motel, etc.) FOR COMMERCIAL USE r 0 <br /> ft. x . . . . . . . . ft. Plans Submitted . . . . . . ,a-,: <br /> A . .T. . sq. ft. Plans Approved <br /> ------ <br /> �' •, Fig. A. Location of proposed structures and <br /> existing structures, well, sewage sys- O <br /> terns, roads, etc., should be sketched <br /> in Fig. A. Include road setback, side in s <br /> and back yard dimension and location 2 a <br /> and setback from all bodies of water. ey <br /> J�9 If property is located at a highway in- <br /> tersection, show the intersecting high- : n <br /> p ways and the setbacks required along <br /> �e x( q a them and at the intersection. <br /> 717/ PERMIT FEES <br /> d <br /> '7S Subdivision $15.00 <br /> ar, Land Use . . . . . . . . 1.00 <br /> Building . . . . . . . . . . 1 <br /> Sanitary . . . . . . . . . . <br /> Well . . . . . . . . . . <br /> Septic Tank . . . . . . . 10.00 - <br /> Combination Building, Sanitary <br /> and Well 15.00 <br /> Privy . 5.00 <br /> O <br /> ...... . ......... <br /> Signatur f Owner or Agent ate,9 nin ministratpr <br /> -7 <br /> Inspection Date . ...�� / Inspector �,/—j`L�I:�Ct.Cl/' .,i'C.��`l�-�r--�'.................... <br /> Remarks .. . .......................... <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 />