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<br /> Burnett County Office of Zoning Administrator N v
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<br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ,. 3CD
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<br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a _ o k
<br /> Permit for the work described and located as shown herein. The undersigned agrees that all 0,
<br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, c
<br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu °-
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<br /> lations of the Staof Wisconsin. d O
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<br /> Owner�r Agent (please print) Contractor or Surveyor
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<br /> Address Address o-
<br /> Phone Phone a. 0 rer4.01564 _ ,/,4. 1 a
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<br /> Plumber • • Well Driller
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<br /> /3 SMf / / si sNtittc! T, o k
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<br /> Address Address o o N,
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<br /> Phone Phone co v,o
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<br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities:
<br /> Type of Construction No. Bathroomso
<br /> 1. Work ` o_ No. Bedrooms • cp
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<br /> New Building Sizeft. x ft. Septic Tank Size Gals. '� _ .-
<br /> Addition Height Stories ��
<br /> Sanitary f'' Area 7a.Absorption Field Site:�> �b�ii j3eVC1 "�l m ;�
<br /> Filling Soil Type .'3". . .t✓/. . . . . . . . c sl l� o
<br /> Moving 5. Permits Required Slope ',
<br /> Grading Subdivision Perc. Rate
<br /> Mobile Home Sanitary s.— Dry Well k
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<br /> Privy Building Seepage Trench Cl)
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<br /> Well Well Privy 1
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<br /> Subdivision Other (Specify) Seepage Bed I".X.9.1 o
<br /> Conditional y/O 5 /�r Cl) Cl)
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<br /> 2. Classification Land Use 6 _
<br /> Zoning Dist. <' o
<br /> 6. Use (describe exactly, 1 -fam.
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<br /> 3. Lot Size id ffe YDS home, motel,etc.) FOR COMMERCIAL USE t •
<br /> ft. x ft. Plans Submitted ...C-:-
<br /> sq. ft. Plans Approved
<br /> ^/O1`rc .!f:1 /{ Fig. A. Location of proposed structures and —1
<br /> J---,Z- Vie--i 7 #--c u ,v, existing structures, well, sewage sys- o
<br /> bV-et( /ye 7 //tiST/3l/e i) terns, roads, etc., should be sketched
<br /> ti?/// -73-e. ,-4._r A ;its 7- I. in Fig. A. Include road setback, side 1
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<br /> SO 1..--T- F,„,,,,, A/ /Ter and back yard dimension and location
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<br /> and setback from all bodies of water.
<br /> �O 5 If property is located at a highway in- , �"
<br /> `may, tersection, show the intersecting high- \�
<br /> to XLi r f��F.� ways and the setbacks required along ��
<br /> them and at the intersection.
<br /> (f►�� PERMIT FEES
<br /> j� 1 - i Subdivision $25.00 + $2.00 per lot. Co
<br /> I I i 1 0 I1 eF 9fl Land Use $10.00
<br /> 4 r� ' +` Building 10.00
<br /> 7 � D -11 o�13> :1::
<br /> Sanitary C_0.0Q)C 3(� ( f Well 10.00
<br /> i d i ( — k .pSeptic Tank 10.00
<br /> y Privy 5.00
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<br /> Signatureof Owner or Agent Date /� Zo.i•g • dministraatttoo`rr
<br /> Inspection Dated:- cZ7 7,T Inspector '1' r� `�- " tee'r e � 2 ""�
<br /> Remarks l./lr2.' C— --�'— -- 7-e
<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.
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