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<br /> Burrlett County Office of Zoning Administrator o z
<br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT roCD
<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 y "'`^
<br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, (�
<br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- v ° 3
<br /> lations of th,e State of Wisconsin. -' a p
<br /> DC11 t tiJ 1 IV A ,E.t : - °
<br /> Owner or Agent (please print) Contractor or Surveyor y `�'
<br /> c N % vi
<br /> 7 '371 5-y, rh,, ,7 a °((; Q
<br /> Address Address a 3
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<br /> Phone / Phone `�V �i
<br /> A Lr.-1---=-,--
<br /> Plumber Well Driller
<br /> Address Address - 0
<br /> •�, rq'"At;
<br /> Phone Phone C H I—
<br /> ��7` m o 0
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<br /> D ESC R I PT 10 N 4. Building Details 7. Sanitary Facilities: °
<br /> Type of Construction No. Bathrooms Z Z °
<br /> 1. Work No. Bedrooms . ° CD
<br /> New Building Size ft. x ft. Septic Tank Size Gals. ,,, ,N .''▪ Z t''.1
<br /> Addition
<br /> / Height Stories 7a.Absorption Field Site: /
<br /> �` '1 m C.-
<br /> Filling �,/ Area P '
<br /> Filling Soil Type 1 o
<br /> Slope
<br /> Moving 5. Permits Required -'s,� 1
<br /> Grading Subdivision Perc. Rate ICJ. T _ 41
<br /> Mobile Home Sanitary z---••''''�•� Dry Well I
<br /> Privy Building Seepage Trench C L
<br /> 91
<br /> Well Well Privy g
<br /> Subdivision Other (Specify) Seepage Bed �. � •J� 4
<br /> Conditional • N N
<br /> c co
<br /> 2. Classification Land Use I cr
<br /> Zoning Dist. ---, \ a o•
<br /> VI 6. Use (describe exact) , 1 fam. ° y' J
<br /> 3. Lot Size home, motel, etc.) FOR COMMERCIAL USE I '5 °
<br /> ft. x ft. Plans Submitted G o
<br /> r .O. .".-2. :'i." . . . sq ft. Plans Approved C \ T"
<br /> •Fig. A. Location of proposed structures and
<br /> texisting structures, well, sewage sys- o
<br /> (� G' __ _._ ``- tems, roads, etc., should be sketched �, 3
<br /> in Fig. A. Include road setback, side 3
<br /> t.. and back yard dimension and location -o
<br /> u��-(2 ^ , I4r and setback from all bodies of water.
<br /> rC""t` ...7,,...7,, ,� �u, If property is located at a highway in- .?
<br /> 1 , or f.,F tersection, show the intersecting high- c�
<br /> -_ .
<br /> ways and the setbacks required along ^
<br /> them and at the intersection. ( cl
<br /> I ia PERMIT FEES
<br /> Subdivision $25.00 + $2.00 per lot. `D
<br /> 1 gx3tt' Land Use $10.00 rk,
<br /> Buil ' 10.00
<br /> anitary
<br /> 10.00 a
<br /> Septic Tank 10.00 ,\.
<br /> Privy 5.00
<br /> i----L, .,_ .,7 ,„„ -I 7 - a)
<br /> QL `,Lvt„ a .
<br /> ZoningAdministrator
<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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