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Burnett Cour•ty Office Of Zoning Administrator` �m / o z <br /> m m m 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT °. 3 r <br /> ' V <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a = /R 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, 77 m v� <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- ' °- <br /> lati s of the State of Wisconsin. a <br /> TER/SCANN _. <br /> l . . . . . . . .•. . . . . . . . . . . . . . . . . N COMPU. . . . . . . . <br /> Owner or Agent (please print) Contractor or Surveyor <br /> c <br /> :3 Address j 6 CL <br /> Sof�� Address a , <br /> m <br /> P Phone <br /> 1 ; <br /> . . . . . . . . . . . . :M <br /> umber Well Driller <br /> Address Address o <br /> . . . .. 3 .y. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . � :rte <br /> Phone Phone �� 7 <br /> � H r- <br /> 0 0 N <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities / 'o v <br /> Type of Construction No. Bathrooms . . z Z0 <br /> 1. WorkDishwasher o <br /> New Building V. Size . . . . . ft. x­.'.*.*.*.*.' <br /> ft. Garbage Grinder . . . . . . _� � 1\ <br /> Addition Height . . . . . Stories . . . . . . Autom. Laundry /. . . . :l, <br /> Sanitary . . Area No. Bedrooms . .7 , r <br /> Alterations . . . . . . Waste Disposal System 4(C . . o <br /> • A <br /> Moving . . . . . . 5. Permits Required Septic Tank Size Gals. 7S0 w` <br /> Wrecking . . . . . . Subdivision . . . . . . Absorption Field Site T <br /> Mobile Home Sanitary Soil Typet� <br /> Privy . . . . . Building Slope . . ..�>.l4- . . . . . . . . . . . :a� <br /> Well x. . . Well X . . Perc. Rate . . .3. . . . . . . . . . . . ;�}1 <br /> Subdivision . . . . . . Other (Specify) . . . . . . Dry Well . . . . . . <br /> Conditional . . . . . . Seepage Trench N N <br /> 2. Classification �/ / Land . . . . . . Privy c <br /> Zoning Dist. . . . . . Seepage Bed . . . . . . a o <br /> 6. Use (describe exactly, 1 - fam. - <br /> 3. Lot Size home, motel,etc.) FOR COMMERCIAL USE *, C=O-, <br /> . . . . . . . . . ft. x . . . . . . . . ft. Plans Submitted ��� <br /> . . . . . . . . . . . . . . . . . . sq. ft. Plans Approved . . . . . . , ) <br /> --------------------- -------------------------proposed <br /> p------------ <br /> Pro o <br /> Fig. A. Location of sed structures and ) <br /> existing structures, well, sewage sys- <br /> tems, roads, etc., should be sketched <br /> in Fig. A. Include road setback, side ( � :O <br /> and back yard dimension and location ;`: -o <br /> and setback from all bodies of water. <br /> If property is located ata highway in I N <br /> tersection, show the intersecting high- \\\ <br /> ways and the setbacks required along <br /> them and at the intersection. <br /> PERMIT FEES ; <br /> Subdivision . . . . . . . . . $15.00D <br /> Land Use . . . . . . . . . . . 1.00 <br /> Building 5.00 <br /> Sanitary <br /> Well . . <br /> Septic Tank IQ.00 � •� <br /> Combination Building, Sanitar <br /> and Well . . . . . . . . 15.00 <br /> fi <br /> �r� 7. ` h� ............................. <br /> Signature of Owner or Agent Date Z g Administrator <br /> C <br /> InspectionDate ..................../.. Inspector ... .. ....... ................... -...................................................... <br /> Q�.........�.. .•o p. / <br /> Remarks .. /!.... 1` G'...�..G...G�...... ......... I2�/... .f-: <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 />