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CI ) WIa ) <br /> Burnett County Office of Zoning Administrator cn -0 o <br /> m C d O O <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT '°. 3 <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 N <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, 777 CD <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- -CD <br /> ° <br /> lations of the State of Wisconsin. °- � <br /> 3 � � <br /> �. r' `� h. ' 1 .�`.� .f' KCD <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . _ ID <br /> Owner or Agent (please print) Contractor or SurveyorCD <br /> N ; <br /> c � <br /> Address Address a ( n <br /> h '-1 <br /> 4 C. ..L. . . . .`.�i h. . . . . . . ... . . . . . .` <br /> P . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> . . . 1 ; <br /> Phone Phone <br /> !. . �. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , <br /> Plumber. . . . . . . . . . . . <br /> Well Driller <br /> ZIQ p <br /> Address Address CD <br /> Phone Phone ID m :� <br /> CD <br /> ° O ) <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: <br /> Type of Construction No. Bathrooms o z <br /> 1. Work . . . .F. / . . .. ..i. . . No. Bedrooms ° <br /> New Building . . . . . . Size . . . . . <br /> ft. x . . . ... ft. Septic Tank Size Gals. <br /> Addition Height . . . . . Stories . . . . . . . . . . . . <br /> Sanitary . . . . ... Area . . . . . . . . . . . . . . . . . . . 7a.Absorption Field Site: r- <br /> Fillin Soil Type . . . . . . . . . . . . . . . . . . ° <br /> Moving . . . . . . 5. Permits Required Slope . . . . . . . . . . . . . . . . . . . . : <br /> Grading . . . . . . Subdivision Perc. Rate <br /> Dry Well CD <br /> �A- -n <br /> Mobile Home . . . . . . Sanitary CD <br /> Privy Building �-�� Seepage Trench . . . . . . fD CD <br /> Well . . . . . . Well •L . Privy <br /> Subdivision Other (Specify) Seepage BedX 31E' c <br /> o �'� 0cn <br /> Conditional ° C <br /> 2. Classification , Land Use <br /> . . . . a <br /> Zoning Dist. - ° <br /> 6. Use (describe exactly, 1 fam. <br /> 3. Lot Size home, motel,etc.) FOR COMMERCIAL USE ° <br /> ° N <br /> ft. x . . . . . . . . ft. Plans Submitted . . . . . . <br /> sq. ft. Plans Approved . . . . . . <br /> ----------------------------------------------------------------- <br /> Fig. A. Location of proposed structures and <br /> existing structures, well, sewage sys- 0 <br /> v 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. <br /> �gX3� F-- 3c' If property is located at a highway in- <br /> 11� tersection, show the intersecting high- <br /> 0, ways and the setbacks required along <br /> them and at the intersection. <br /> PERMIT FEES <br /> --� J Subdivision . . . . . . . . . $15.00 `D <br /> U Land Use . . . . . . . . . . . 1.00 <br /> Building . . . . . . . . . . . 5.00 <br /> Sanitary . . . . . . . . . . . 10.00 <br /> Well . . . . . . . . . . . 5.00 <br /> U Septic Tank 0.0 <br /> � Combination Building, Sanitary� <br /> 1 and Well • 15.0 <br /> Privy . . . . . . . . . . . . 5.00 <br /> .... .. ..... .... . <br /> : ' <br /> Signature of Owner or Agent D te_ Z in g ministrator <br /> Inspection Date ....... Inspector ..1 -,14KV.r, .a- w%.or... .............................. <br /> Remarks :..... .. ......................................... <br /> ............................................................................................................................................................................................... <br /> ............................................................................................................................................................................................... <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilitie <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached tc <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 />