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Burnett County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> n <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 a '^ <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, x :� <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- <br /> lations of the State of WisConsin. prr0�� 3 O <br /> . .t. . . <br /> (pl .ease. . . . . . . . . . . . . . . . . . . . . . .Cont. . . .ractor. . .or. .Sur. .veyor. . . . . . . . . . . . . . . . . . . . . . . <br /> Owner or Agenprint) <br /> - 7 S7VRdttt� R %�� A/D /LIARKY.�cE <br /> t a V <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . r. . . . . . . . . . . . . <br /> Address � � � Address <br /> U <br /> 067649.7 <br /> 4U4, 710A/ <br /> Phone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Phone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> . . . . . . . <br /> Plumber Well Driller : ' d <br /> 0 <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Address - <br /> °. <br /> . . .ne. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> PhoPhone 0 <br /> o <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities -o <br /> Type of Construct}'Qn' No. Bathrooms . . .tZ. . Z Z o <br /> 1. Work . . . G . . .. . . Dishwasher . . ° ° <br /> New Building . x . . Size .5' ..ice'' . 4Ww♦!P Garbage Grinder . . . . . . � <br /> Addition . . . . . . Height Ston Autom. Laundry . .&. . <br /> Sanitary . .X. . Area ..� ?�.?!! 4/�f�,90 No. Bedrooms �.y;. . rZ z � <br /> Alterations . . . . . . bF/B�v,ma Waste Disposal System .$QQ,yCe' o <br /> Moving . . . . . . 5. Permits Required Septic Tank Size Gals. EL940d <br /> Wrecking . . . . . . Subdivision . . . . . . Absorption Field Site ' <br /> Mobile Home �. . . . . . . . T m <br /> Sanitary . . x. Soil Type . . . . . . . . . m <br /> Privy . . . . . . Building . . . Sloe . . . . . . . . o <br /> Well Well . . . x Perc. Rate . . . . . . . . . .� . . . . . . <br /> Subdivision . . . . . . Other (Specify) . . . . . . Dry Well . . . . . . o Q v <br /> C <br /> Conditional . . . . . . Seepage Trench ( y w <br /> 2. Classification Land . . . . . . Privy . . . . . . <br /> Zoning Dist. . . . . . . Seepage Bed >11 <br /> A <br /> 6. Use (describe exactly, fam. <br /> 3. Lot Sizeome, oteI,etc.) OR COMMERCIAL USE / - 2 ' <br /> t�. . . .. ft. Plans Submitted . . . . <br /> .S . . ..!`.'1. .. . sq. ft. Plans Approved ° (c� <br />------------------------------------------------------------------ <br /> Fig. A. Location of proposed structures and J . <br /> existing structures, well, sewage sys- 0 <br /> s, roads, etc., should be sketched ° <br /> 7in Fig. A. Include road setback, side s <br /> j% and back yard dimension and location <br /> o�o and setback from all bodies of water. ^, <br /> W ryp 1�, If property is located ata highway <br /> in-tersection, show the intersecting high- _ <br /> ,fig ao ftI ways and the setbacks required along <br /> d � them and at the intersection. <br /> PERMIT FEES <br /> �QlLl6 Subdivision $15.00 `D <br /> Wim-- Land Use . . . . . . . . . . . 1.00 ' <br /> ygr3f. (//14f!!f Building . . . . . . . . . . . 5.00 <br /> Sanitary . . . . . . . . . . . 10.00 </I <br /> e Well . . . . . . . . . <br /> 5. <br /> Septic Tank <br /> 3 Combination Building, Sanitary <br /> yeS• and Well . . . . . . . 15.00 ' <br /> Signature of Owner or Agent 4/Date ning min istrator <br /> InspectionDate ................................................ Inspector ................................................................................................ <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 />