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elL <br /> Burnett County Office of Zoning Administrator ' z <br /> CD CD CO 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ° CD <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 d H \ <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, c 0 • <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- -v °- <br /> lations of the State of Wisconsin. CD a . � <br /> d <br /> . .,d/./Ir— . . . . <br /> ,-' CD a <br /> Owner or Agent lease pr. t) Contractor or Surveyor N <br /> kX./f. <br /> CD <br /> A` Address <br /> CO. <br /> m <br /> Phone Phone <br /> • <br /> Plumber Well Driller <br /> N <br /> Address Address m C) <br /> n o <br /> ., < <br /> o ,-i <br /> Phone Phone CD y r- <br /> n ,.., 0 <br /> (a o '' <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: -° <br /> Ty f Co str +ction No. Bathrooms o z oa <br /> 1. Work . . . No. Bedrooms <br /> o m <br /> New Building . . . . . Size .�0. ft. x . �ft. Septic Tank Size Gals. / ‘ .- <br /> Addition Height Stories Le <br /> r <br /> Sanitary Area 7a.Absorption Field Site• <br /> Filling Soil Type o <br /> e <br /> Moving 5. Permits Required Slope <br /> Grading Subdivision Perc. RateCNN <br /> Mobile Home Sanitary Dry Well CD CD <br /> Privy �^ Building Seepage Trench `D CD <br /> Well �/ Well (, — Privy <br /> Subdivision Other (Specify) Seepage Bed o <br /> -k ,, <br /> Conditional N N <br /> 2. Classification Land Use np <br /> Zoning Dist. ° o <br /> 6. Use (describe exactl 1 -fam. y', <br /> 3. Lot Size hom otel,etc.) FOR COMMERCIAL USE ° <br /> ft. x ft. <br /> /q Plans Submitted <br /> . . , id d . . . sq. ft. Plans Approved f�� ll,.. <br /> — W <br /> Fig. A. Location of proposed structures andCV <br /> existing structures, well, sewage sys- ' o <br /> X (ve/l tems, roads, etc., should be sketched a <br /> in Fig. A. Include road setback, side �) ? <br /> and back yard dimension and location o <br /> i iand setback from all bodies of water. <br /> a �' If property is located at a highway in- ((�� <br /> /Por�re tersection, show the intersecting high '> <br /> 14)i -ec' ways and the setbacks required along I <br /> 1 b,j them and at the intersection. <br /> --,` /3•-Q PERMIT FEES .. <br /> %% 1 Subdivision $25.00 + $2.00 per lot. `° <br /> ) r r Land Use $10.00 <br /> Building 10.00 <br /> Sanitary 20.00 <br /> / 0 fie, re Well 10.00 k. <br /> SlTe_. Septic Tank 10.00 <br /> Privy 5.00 <br /> 7,17 <br /> Signature of Owner or Agent �te Zo( 4thminitrator <br /> Inspection Date Inspector <br /> Remarks <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 he made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />