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Burnett County Office of Zoning Administratorl!T ' <br /> cn -0 i <br /> m m y 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT �, 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a 0 <br /> Permit for the work described and located as shown herein. The undersigned agrees that all H <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, x m <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- M ° I <br /> no ns of the State of Wisconsin. a (� <br /> 3 C <br /> _ O <br /> D.r�a a. . . . . Y . . . . . . . . . . . . . . . . . . . . c - <br /> Owner or Agent (please print) Contractor or Surveyor <br /> 1 O <br /> �"(� <br /> CL <br /> Address 7a� Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M v <br /> .(n.i . . . . . . . . . . . . . . . . . . . . .� <br /> P e _ Phone (� <br /> : f <br /> . �Wo <br /> Plumber Well Driller Uz <br /> Address Address 0 � <br /> ?7. <br /> 6 — /. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> o " <br /> Phone Phone <br /> � o <br /> o <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: <br /> Type of Construction No. Bathrooms . . • . . • o Z �° ¢ <br /> 1. Work No. Bedrooms �• • • 0 <br /> New Building . . . . . . Size . . . . . ft. x . . . . . . ft. Septic Tank Size Gals. <br /> Addition . . . . . Height . . . . . Stories . . . . . . <br /> Sanitary Area . . . . . . . . . . . . . . . . . . . 7a.Absorption Field Site: <br /> Filling Soil Type . . . . . . . . . . . <br /> Moving . . . . . . 5. Permits Required Slope U.✓c�. . . . . . . . . . . . . . <br /> Grading . . . . . . Subdivision Perc. Rate .3. -.Y.-.Y. . . . . . . . T <br /> Mobile Home . . . . . . Sanitary +/, Dry Well . . . . . . <br /> Privy . . . . . . Building Seepage Trench . . . . . . <br /> Well . . . . . . Well . . . , , , Privy . . . . . . <br /> Seepage Bed . . . . . . o <br /> Subdivision . . . . . . Other (Specify) . . . . . . o I ti <br /> Conditional . . . . . . <br /> 2. Classification Land Use . . . . . . a <br /> Zoning Dist. . . . . . . ;P 0 <br /> 6. Use (describe exactly, 1 -fam. t <br /> 3. Lot Size home, motel,etc.) FOR COMMERCIAL USE 0 <br /> ft. x . . . . . . . . ft. Plans Submitted . . . . . . <br /> a: :icc ,. . . . . - Plans Approved . . . . . . <br /> ------------------------------------------------------------------ <br /> Fig. A. Location of proposed structures and <br /> existing structures, well, sewage sys- I 5j 0 <br /> tems, roads, etc., should be sketched <br /> in Fig. A. Include road setback, side <br /> and back yard dimension and location <br /> and setback from all bodies of water. tSSSS <br /> If property is located at a highway in- <br /> tersection, show the intersecting high- , I \ <br /> ways and the setbacks required along <br /> j them and at the intersection. <br /> PERMIT FEES ) <br /> J � <br /> t � <br /> Subdivision $15.00 Q `D <br /> Land Use . . ^l) <br /> �I Building . . . . . . . . . 55.00 <br /> Sanitary . . . . . . . . . . . "I�D0 <br /> /� � 7S-b GAC Well . . . . . . . . . 5.00 <br /> pro Septic Tank 10.00 <br /> i o a..ccoaP <br /> �ICombination Building, Sanitary <br /> ell)t and Well . . . . . . . . 15.00 <br /> COAttd Y�,Qw Privy . . . . . . . . . . . . 5.00 <br /> %......:................... . . . . .... . . .............. ....7....../...:... .. .. <br /> Signature of caner or Agent Date Hing ministrator <br /> Inspection Date . :... j.`.. X..................... Inspector ..i.�.�l ?- �..5 .:..... ................. ............................... <br /> Remarksi .Z�... ........lL�)!LC� !_f� ✓. :`.` .................... <br /> .... ...... .... e: :........................................................................ <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 />