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Burnett County , Office of Zoning Administrator 4 11 0 H .o z <br /> 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a = <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, C .-� \* <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- a `l: <br /> lations of the State of Wisconsin. 3 a I�. : 0 <br /> J <br /> Owner or A ent (please print) Contractor or Surveyor H <br /> . ..,..$' L <br /> Address Address a <br /> \ , <br /> i ,,k 1 ,r\.'1 <br /> Phone Phone V�� <br /> Plumber Well Driller * <br /> Address Address 7,) 0 <br /> o <br /> ��- � a �' ` <br /> o� <br /> Phone Phone CD y <br /> CD• •, o <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: • v <br /> Typ�,gf r,Uction No. Bathrooms / o z -o <br /> 1. Work �If /` No. Bedrooms o CD y <br /> New Building Size ft. x ft. Septic Tank Size Gals. 7 ' G <br /> Addition Height Stories Cr <br /> Sanitary .:-�" . . Area 7a.Absorption Field Site: r <br /> Filling Soil Type o <br /> Moving 5. Permits Required Slope .. � e .� ° <br /> Grading Subdivision Perc. Rate . . . 417.1.44/ • <br /> Mobile Home Sanitary Dry Wellco ib <br /> Privy Building Seepage Trench co <br /> Well Well Privy :i ' <br /> Subdivision Other (Specify) Seepage Bed �` <br /> Conditional - N <br /> 2. Classification Land Use r" Ei h <br /> Zoning Dist. -. o <br /> 6. Use (describe exactl. ^ o' <br /> 3. Lot Size /7 home, motel,etc.) FOR COMMERCIAL USE 4 fx ft. Plans Submitted <br /> I.lO. .4. .0 l �. . . sq ft. Plans Approved N <br /> o <br /> Fig. A. Location of proposed structures and <br /> existing structures, well, sewage sys- ?' r.—o <br /> tems, roads, etc., should be sketched <br /> 0. <br /> 1 t 't in Fig. A. Include road setback, side <br /> fV and back yard dimension and location � :"� <br /> x , <br /> and setback from all bodies of water. Ci\ <br /> If property is located at a highway in- _. ,, <br /> tersection, show the intersecting high- y, <br /> ways and the setbacks required along O -' <br /> 12- them and at the intersection. <br /> C-II/ <br /> PERMIT FEES <br /> fj)4 Subdivision $25.00 + $2.00 per lot. '- co <br /> L0p6 Land Use $10.00 .1 ; , <br /> .1 Building 0.00 <br /> r Sanitaryy 20.00 <br /> /a SVC/ ± Well 10.00 <br /> Septic Tank 10.00 <br /> DP( 4rL�_ <br /> , Privy 5.00 <br /> ..\1 ..--/ <br /> 4,07 0-02-c.„,0--,___ F---e 7 8----e-e i.., f-i /i <br /> .., .1"7 : ddli/it., <br /> Signature of Own r� or Agent Date oning Adm nistrator <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 he made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />