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Burnett County Office of Zoning Administrator N - o -I z
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<br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3
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<br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a -I �. o
<br /> Permit for the work described and located as shown herein. The undersigned agrees that all a,
<br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, xC
<br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- °
<br /> lations of the State of Wisconsin. CD_
<br /> 3 d \y� y 0
<br /> Owner or Agent (please print) Contractor or Surveyor c
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<br /> Address fi/•�v/.0,44,v was /6 Address a ,....,_
<br /> 7i,S: . 34. "4e9 .. b",�' ' e7c . G '/ "-P I k
<br /> Phone Phone ,N1 O
<br /> Plumber Well Driller
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<br /> Address Address ca o
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<br /> Phone Phone
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<br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: -o
<br /> Type of Construction No. Bathrooms o z °
<br /> 1. Work .zr.:. ,7-•-- No. Bedrooms °
<br /> New Building . /. . . Size ft. x .4a. ft./ v Septic Tank Size Gals. .Z
<br /> Addition Height Stories
<br /> Sanitary Area 7a.Absorption Field Site: m
<br /> Filling Soil Type p o
<br /> Moving 5. Permits Required Slope
<br /> Grading Subdivision Perc. Rate 9 )
<br /> Mobile Home Sanitary Dry Well I co � w
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<br /> Privy Building . ,X, , Seepage Trench CD
<br /> Privy VI °` Ld
<br /> Well Well ,
<br /> Subdivision Other (Specify) Seepage Bed (S� o
<br /> Conditional Cl) N
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<br /> 2. Classification 9 Land Use I (� a 0
<br /> Zoning Dist. f g:-. Q I12 z' °
<br /> 6. Use (describe exactly, 1 -fam. N' 7
<br /> 3. Lot Size home, motel,etc.) FOR COMMERCIAL USE l� °
<br /> . 7. . . ft. x /d 0 ft. Plans Submitted �,
<br /> sq. ft. Ls-e- Plans Approved c. 6\
<br /> Fig. A. I Location of proposed structures and
<br /> '/, existing structures, well, sewage sys- 1 o
<br /> 20E' ,; q/ tems, roads, etc., should be sketched H
<br /> /� � in Fig. A. Include road setback, sideki'
<br /> and back yard dimension and location 7a t .o
<br /> (1,,, __. and setback from all bodies of water. ��
<br /> rFy�.S�,ei6 If property is located at a highway in-
<br /> 4./mile efp./mile tersection, show the intersecting high- :
<br /> ways and the setbacks required along \
<br /> them and at the intersection.
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<br /> PERMIT FEES ,�
<br /> Subdivision $15.00 \ `j fD
<br /> Zf V/?-e low. 76v/ere Land Use 1.00 ,�
<br /> Building 5.00
<br /> Sanitary 10.00 k
<br /> Well 5.00 it' •
<br /> Septic Tank 10.00 Q
<br /> ` -}-� ICJ M Combination Building, Sanitary t,
<br /> --�-.—�Q __ and Well 15.00
<br /> Privy 5.00 `�
<br /> gi‘:?lee.-- '*"�./t._C--1 7--/7.8/ . �5.... "
<br /> Signature of Owner or Agent Date Zoni Administrator
<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 be made without approval of the Zoning Administrator.
<br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED.
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