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Burnett County Office of Zoning Administrator N o H z <br /> CD m o <br /> APPLICATION FOR SANITARY — LAND USE — Bu'1LDING PERMIT a' , CD <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a -I rt :it...4o <br /> Permit for the work described and located as shown herein. The undersigned agrees that all co H <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- -o ° • <br /> la ions of the State'of1Wisconsin. _ a <br /> e4hLic e. <br /> 41064-4R6 \hr. <br /> Owner or Agent (please print) Contractor or Surveyor N `' <br /> 5530W q ' 51," 6310, � tiluv. <br /> A ress / 531/37' Address a + <br /> (404) g35---440 3.2_ - <br /> Phone Phone r <br /> Plumber Well Driller v (.' <br /> 0 _ <br /> Address Address Gc } <br /> C) 0 `-- <br /> Phone Phone co H <br /> CD o <br /> o <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities -a <br /> Type of Construction No. Bathrooms z z o <br /> S. <br /> o <br /> 1. Work Dishwasher ° <br /> -,T, <br /> �' <br /> New Building Size ft. x ft. Garbage Grinder2. . . <br /> _� <br /> Addition Height Stories Autom. Laundry a <br /> Sanitary Area No. Bedrooms 1- <br /> Alterations Waste Disposal System ° <br /> Moving 5. Permits Required Septic Tank Size Gals. <br /> Wrecking Subdivision Absorption Field Site <br /> Mobile Home Sanitary Soil Type CD m <br /> Privy Building Slope -ea CD fa <br /> Well Well Perc. Rate $- '-- <br /> Subdivision Other (Specify) Dry Well o o <br /> t=l 1 I 1 J Co 0Conditional Seepage Trench cn cn <br /> 2. Classification Land Privy <br /> Zoning Dist. Seepage Bed co_ o' <br /> 6. Use (describe exactly, 1 -fam. y. <br /> 3. Lot Size home, motel,etc.) FOR COMMERCIAL USE ° <br /> ft. x ft. Plans Submitted <br /> sq. ft. Plans Approved ` ,6.-' <br /> Fig. A. Location of proposed structures and I H <br /> existing structures, well, sewage sys- ° <br /> 5E r�t1'r4cffED F/ _-� pLA- 1 tems, roads, etc., should be sketched <br /> 1`T IT l.0 N <br /> in Fig. A. Include road setback, side ° <br /> z <br /> and back yard dimension and location , \ -3. <br /> and setback from all bodies of water. ,j , <br /> If property is located at a highway in- "� <br /> tersection, show the intersecting high- - 0 <br /> ways and the setbacks required along <br /> them and at the intersection. <br /> PERMIT FEES <br /> Subdivision $15.00 co <br /> Land Use <br /> Building 5. 0 <br /> Sanitary 10.00 <br /> Well 5.00 <br /> Septic Tank 1.00 <br /> Combination Building, Sanitary <br /> and Well 15.00 <br /> if <br /> 9 . 9 /9 7 7 S,.ci.A.. a <br /> gal <br /> Signature of O gr or Age Date Zoni g Adminer..„.4.4.........Av <br /> tor <br /> Inspection Date .. ' °/4 ( Q -77Inspector ` cam., <br /> -.4,-C -*""'") . il- 071Z- <br /> NOT . A preliminary site inspection must be made and site approval gra ed 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 />