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Burnett County Office of Zoning Administrator N o /Z <br /> d o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT °, 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application fora <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, <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- _0 °- <br /> lations of the State of Wisconsin. 3 <br /> / ` q C A7 <br /> w or�jAg`ent,(yplease print) Contractor or Surveyor N :\ <br /> 6S,0'fv <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Address Address <br /> 3 . <br /> . . . . . <br /> Phone Phone <br /> . <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . t <br /> V <br /> Plumber Well Driller <br /> 4 <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> O <br /> Address. . . . . . . . . . . . Address n o <br /> o µ <br /> Phone Phone ' 0 \\ \ <br /> DESCRIPTION 4. BuildingDetails v <br /> 7. Sanitary Facilities: C <br /> Type of Construction No. Bathrooms o Z 0 <br /> 1. Work , No. Bedrooms 0 � <br /> New Building <br /> . . . . . . Size r1 : . ft. x !�. .� ft. Septic Tank Size Gals. . . . . . . <br /> Addition . . . . . . Height .!r . Stories . . . . . . . . . . . . .\ <br /> Sanitary . . . . . . Area . . . . . . . . . . . . . . . . . . . 7a.Absorption Field Site: :h <br /> Filling . . . . . . Soil Type . . . . . . . . . . . . . . . . . . : o: 0 <br /> Moving . . . . . . s <br /> . . . . . . 5. Permits Required Slope . . . . . . . . . . . . . . . . . . . . 1 <br /> Grading . . . . . . Subdivision Perc. Rate . . . . . . . . . . . . . . . . . oN <br /> Mobile Home . . . . . . Sanitary v Dry Well . . . . . . w ' <br /> Privy . . . . . . Building Seepage Trench . . . . . . Z'° <br /> Well . . . . . . Well . . . . . . Privy . . . . . . y' <br /> �J <br /> Subdivision . . . . . . Other (Specify) . . . . Seepage Bed . . . . . . G o :v <br /> Conditional . . . . . . <br /> 2. Classification Land Use . . . . . . o o' <br /> Zoning Dist. . . . . . . �v' o. <br /> - o <br /> 6. Use (describe exactly, -fam <br /> 3. Lot S ome motel,etc.) FOR COMMERCIAL USE <br /> ft. x v15�-5. . . ft. Plans Submitted . . . . . . � <br /> . . . . . . . . . . . . . . . . . . sq. ft. Plans Approved . . . . . . <br /> `J <br /> Fig. A. Location of proposed structures and <br /> `7 - existing structures, well, sewage sys- 0 <br /> tems, roads, etc., should be sketched <br /> r in Fig. A. Include road setback, side �� s <br /> .J and back yard dimension and location ,A <br /> _ - -- --___ _ and setback from all bodies of water. <br /> If property is located at a highway in <br /> tersection, show the intersecting high <br /> Tfaa i / i � ways and the setbacks required along <br /> them and at the intersection. <br /> PERMIT FEES 3 <br /> Subdivision $15.00 <br /> 4 <br /> � Land Use . 1.00 <br /> Building . . . . . . . . . J,5.00 <br /> Sanitary . . . . . . . . . . . 10.00 i <br /> Well . . . . . . . . . 5.00 <br /> USeptic Tank . . . . . . . . . 1.00 <br /> L F- Combination Building, Sanitary <br /> a <br /> and Well 15.00 <br /> - - Privy . . . . . . . . . . . . 5.00 <br /> f�OA I <br /> z <br /> ` .. T7�:-....... g ........ <br /> Signature of 0 n or A ent Date 4wn n Administrator <br /> Inspection DateX .r �:Y/. Inspector ................................................................................................. <br /> ............. ........ � / T <br /> t <br /> : <br /> Remarks ....... ...._ :. ......^.,v............ ........_.......... .....__.._... ��. <br /> �........,.:.�'.<.. ls:.g.:............................._...................................................................................................._................. <br /> <<:...x:.,3,3 ..._...1­­,!_�_.t.#fi.�r1.:Fc5............................................................................................. <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 />