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NUKlrivvwL iii-,. - . <br /> • /��' ROUT <br /> W TER, WISCONSIN 5489`3 <br /> 5-349-5450 <br /> V' Fig. A. <br /> ,Location of proposed structures and <br /> existing structures, well, sewage sys- <br /> tems, roads, etc., should be sketched <br /> in Fig. A. Include road setback, side <br /> m � l/ and back yard dimension and loca- <br /> �� U tion and setback from all bodies of <br /> n'^ water. If property is located at a <br /> highway intersection, show the inter- <br /> ^ secting highways and the setbacks <br /> required along them and at the - <br /> tersection, together with vision clearar- <br /> \�, �e \ ance triangles. <br /> PERMIT FEES <br /> ` 1'\ Land Use . . . .. .. .. .. .. .... .$ 1.00 <br /> Building . . . . . .. . . . .. .. .. .. . 5.00 <br /> p��' ✓/v Sanitary . . . .. . ... . . . . . . .. .. 10.00 <br /> Well ... . ... .... .. .. .. .. .. . . 6.00 <br /> Septic Tank <br /> . .......... . .. <br /> • <br /> Combination Building, Sanitary <br /> and Well ..... .. .. .. .. .. 15.0 <br /> CIO <br /> 4� 674__ <br /> /,�4 Co oaal .... �C,� ..G`��- °Signature of Owner or Date Adst r <br /> ACTION Site approved (date) . . . .. . . .. j� <br /> Permit Issued (date) .. . . .. ....!: .!��?. Receipt No.a C//� Fee <br /> Septic Tank Permit Issued (date) . . ..7-!33- .. .. .. . NO &5...�7. Fee $1.00 <br /> Conditional Permit Issued (date) . .. .. .. . . .... ... . .. .... . No. . ........... Fee $. . .... .. . ... <br /> Certificate of Compliance Issued (date) . .. . . . .. . . .. . . .. . . .. .. ............ .. .. ... . . . . . .. . . ... <br /> Permit Denied (date) . .. . . . . . . . . . . . . .. . . . . .. . . . for the following reasons ........... .. .. .... ...... .... . <br /> .. ... . . . .. .... ... ... . . . . . ..... .. .... ..... ... .. . . .. ... .. .. .. .. .. .. .. .. .. .... . . . . . . . . .. .. .. . .. .. . . .. . .. . <br /> Work Started (date) .... ....... . ...... . . . . . Work Co eted (date) <br /> INSPECTION Dat ' .�.��Zk. . Inspector .. . . . �� � <br /> Remaz ..., . . .. . ... .... .. .. ... <br /> �`� .. .. .. . .. . . . .. .... . <br /> . .. ...C:. .�.... ..�. .. ... . ,� 7��` .:. .. ........ .... .. . .. . .. . . . . . .. <br /> . . .. . . . . . . . . . . . . .. .. .. .. .. .......... ............ .. ....... .. .. . . .. .. . . .. .. . ... .. .. .... .. .. . . . . .. .... ... <br /> RECORD <br /> Application to Zoning Committee (date) . .. . . . . . . . . . . . . . . .. . Notice published (date) . .. .. .. .. .. ..... ... <br /> Application to Board of Adjustment (date) . . . . . . . .. . . .. . . . . . Notice published (date) . .. .. .. .. .......... <br /> Appealed to Board of Adjustment (date) . . . . . . .. .. . . . . . . . . . Notice published (date) . . .. ....... ........ <br /> Copy of Notice to DNR (date) . .. .. .. .. . . .. .. .. ..... . . . . .. . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Appeal Heard (date) . .. .. . . .. . . . . . . .. .. .. .. . ... . Decision . . . .. . . .. . . .. . . . . . . . . . . .. .. .. .. .... . . .... . <br /> . . .. . . .. . . . . . . . . .. . . . . .. . . .. .. .. .. . . . . . . . . .. . . . . .. ... . . . . . . . . . . . . .. . .. .. . . . . . .. . . . . .. .. .. .. ........... <br /> Copy of Decision to DNR (date) . . . . . . . .. . . . . . .. .. ... . . .. .. .. . . . . .. . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . <br />