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, j'y) //-,\, ,--10 <br /> Burnett County Office of Zoning Administrator c io 0 <br /> APPLICATION FOR SANITARY — LANDVE - - BUILDING PERMIT ° C <br /> ' <br /> m EN <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a —I ' o : %,4 <br /> Permit for the work described and located as shown herein. The undersigned agrees that all a) H <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, x- <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- v a kN <br /> ► <br /> lations of the State of Wisconsin. - - <br /> a O <br /> e S C j C5wrjeir- — CD <br /> Owner or Agent (please print) Contractor or Surveyor a <br /> Address Address a cu \ <br /> L, Ct Tt0 vl . S -� 3S7 O <br /> Phone Phone • , `j'� <br /> ,,q1*4/15 o.PI m er Well Driller �`� o <br /> Address �`r .� 4. ).. ddrrer s f' ; o , <br /> w E A S �'' 1 <br /> Phone Phone N m . r -, <br /> 0 ,-. 0 <br /> CD ° rr <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: I -° <br /> Typ of Consrl-uctio -7, No. Bathrooms o Z °o <br /> 1. Work (�'`4 lr `'� �`-k Kr 31 1.1• No. Bedrooms • • ° <br /> New Building Size ft. x ft. f777 Septic Tank Size Gals. %, <br /> Addition Height Stories `7•�.0 <br /> Sanitary Area 7a.Absorption Field Site: r <br /> Filling Soil Type ` o <br /> Moving 5. Permits Required Slope \ U\ C <br /> Grading Subdivision Perc. Rate aLA <br /> Mobile Home Sanitary , . — Dry Well CD CD <br /> CD <br /> Privy Building Seepage Trench fD f� T fn <br /> Well Well Privy ,. <br /> Subdivision Other (Specify) Seepage Bed ii. o ' cc) <br /> N <br /> Conditional cam, <br /> 2. Classification Land Use I .70 <br /> a <br /> Zoning Dist. 4 r ' < <br /> 6. Use (describe exact) 1f�a N <br /> 3. Lot Size home, motel,etc.) FOR COMMERCIAL USE ° <br /> ft. x ft. Plans Submitted <br /> l0 �-"Q-4„,_, sq ft. Plans Approved r,% <br /> Fig. A. Location of structures and <br /> proposed I?--. —I <br /> existing structures, well, sewage sys- 0 <br /> terns, roads, etc., should be sketched <br /> — �' min Fig. A. Include road setback, side <br /> ---i3'' -- iax3v, and back yard dimension and location -O. <br /> �f ' and setback from all bodies of water. <br /> / If property is located at a highway in- <br /> tersection, show the intersecting high- --fr <br /> ()�� 5' 111"q� 1-er <br /> J <br /> ways and the setbacks required along I O <br /> 1 1 .5 them and at the intersection. "t <br /> I � <br /> 'Via it PERMIT FEES <br /> K. CC <br /> ,e I Subdivision $15.00 —2 `D <br /> Land Use 1.00 1 <br /> Building 5 s! <br /> Sanitary 10.01 <br /> Well 5�0 :i 1 1 <br /> Septic Tank C 1/0.00 W <br /> Combination Building, Sanitary ( i <br /> and Well 15.00 <br /> Privy 5.00 d <br /> a <br /> (-4 <br /> Signature bf Owner Agent D /7,3 <br /> ate1/ .,.,441. <br /> onin°�;�dministrator <br /> �� �e ',�Inspection Date .. / 7 Inspector .!0 s (.41 r <br /> Remarks /r J e.7`z --/-,' , '...� /„, _ • '' <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 />