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Burnett County Office of Zoning Administrator 0( ` (') <br /> cn -o IPr -I Z <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT aCD <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a -1 '-' o Ni <br /> Permit for the work described and located as shown herein. The undersigned agrees that all 0., " <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, 0 <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- -o lations of the ,State of Wisconsin. �'� 7 a k. O <br /> A4-42- . _I .1r 4-e-i / ' .,7-4-4--3-e-71) ;,- 0 <br /> Owner Agent (please print) Contractor or urvey N 'V <br /> T ,,%%,,�� c r <br /> t .Ri.7 . � . L.'ti' ... . . . f✓�.-t / .;(4)d,z� a }� i <br /> Addres Address o'- V` <br /> 3-& -- 7 .3 <br /> Phone Phone <br /> .L.,..... .,1170-cy3-&-t_ <br /> IP umber Well Driller <br /> Address Address \ o <br /> NA '+ < <br /> o .+ <br /> Phone Phone CD m <br /> n ,� 0 <br /> CD o <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: <br /> Type of Construction No. Bathrooms o oz <br /> 1. Work Z-zY(7. . . -.-r. No. Bedrooms CD <br /> New Building . . A. Size ...Z.' t. x *-2- ft. Septic Tank Size.Gals. • <br /> Addition Height . .�' Stories / a� <br /> Sanitary • <br /> X Area 7a.Absorption Field Site: <br /> W ��r <br /> Filling Soil Type ic o <br /> Moving 5. Permits Required Slope ,v ' <br /> Grading Subdivision Perc. Rate <br /> Mobile Home Sanitary �- Dry Well CD CD <br /> Privy Building J Seepage Trench ro C CD <br /> Well A. Well c— Privy <br /> Subdivision Other (Specify) Seepage Bed o <br /> Conditional N N <br /> c co2. Classification Land Use , c- 0 <br /> Zoning Dist. a Z' o <br /> 6. Use (describe exactly, 1 -fam. y' 7 <br /> 3. Lot Size home, motel,etc.) FOR COMMERCIAL USE o <br /> 7 <br /> ft. x ft. Plans Submitted <br /> sq. ft. Plans Approved <br /> ...,_J_ocation of proposed structures and <br /> existing structures, well, sewage sys- o <br /> Gems, roads, etc., should be sketched = <br /> 7 <br /> in Fig. A. Include road setback, side <br /> and back yard dimension and location 4 -• <br /> and setback from all bodies of water. 4 <br /> /7-te'4s' ‘S. -41.6 " / �/Q y If property is located at a highway in- \ <br /> /'�� d, tersection, show the intersecting high- <br /> hi, /k 1�"7 /641$r'"-.4,77 ways and the setbacks required along <br /> \ 0 ' '''' <br /> them and at the intersection. <br /> / PERMIT FEES <br /> Subdivision $25.00 + $2.00 per lot. `D <br /> / Land Use $1 ..00 _ N <br /> Building 10.00 <br /> / / Sanitary romp O <br /> J 7 / <br /> Well 10.00 <br /> Vff / SepticTank 5.00 -71 <br /> ,// Privy 5.00 <br /> ----- „..1-D A <br /> 43-6- <br /> ignature of OwniT-or Agent Date Zo n Administrator <br /> Inspection Date ,l -30 / r Inspector <br /> Remarks /r-....-7i" C-' -,2-,,, 7z�'i .,_ • <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 />