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Burnett County I Office of Zoning Administrator - " o --1 <br /> CD CD CU 0 <br /> APPLICATION FOR SANITARY — LAND USE —BUILDING PERMIT ° 3 CO • <br /> �• <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a 1 rt o <br /> Permit for the work described and located as shown herein. The undersigned agrees that all H ' . c-.. <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, 77 cp <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- -oa <br /> lations of the State of Wisconsin. o- I <br /> rt CD Owner or Ag nt (please print) Contractor or Surveyor i -° <br /> 4. <br /> gt � � L <br /> Address Address a <br /> i <br /> Phone Phone r' <br /> ens K0 Efr2Pe ( r <br /> Plumber Well Driller I \\ Fjr <br /> .W. ST-c-1 V N o o <br /> Address Address I C) 'A <br /> 66 - e IP <br /> Phone Phone �CD y ot. <br /> 0 <br /> CD 0 r-t N <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: <br /> Type o Co z struction No. Bathrooms • o o a <br /> 1. Work Y / No. Bedrooms CD <br /> New Building Size ` ft. x ft. Septic Tank Size Gals. . <br /> Addition Height Stories �1 <br /> Sanitary . . Area 7a.Absorption FieldSite: r 1 . <br /> Filling Soil Type . .gi,� � 'o <br /> Moving 5. Permits Required Slope - <br /> Grading Subdivision Perc. Rate / r'?f� <br /> Mobile Home k . . Sanitary Dry Well CD m <br /> Privy Building Seepage Trench CD CD (� <br /> Well . .-. . Well �, • • Privy r C <br /> Subdivision Other (Specify) Seepage Bed .-: o . ',. <br /> Conditional C V�V,`l1 N <br /> c CD <br /> 2. Classification jj� Land Use 6 <br /> Zoning Dist. .4. . a o <br /> 6. Use (describe exact 11ffa_m.j �' <br /> 3. Lot Size home, motel,etc.) FOR COMMERCIAL USE o RI <br /> ft. x ft. Plans Submitted d <br /> /0. . .n.Ct S . . sq ft. Plans Approved RN <br /> Fig. A. Location of proposed structures and t., <br /> WELL 141 U �T existing structures, well, sewage sys- � <br /> tems, roads, etc., should be sketched a <br /> (S�' I Fete-- in Fig. A. Include road setback, side 0 E <br /> and back yard dimension and location -o <br /> 7)OA1N Fie—5 and setback from all bodies of water. a <br /> q If property is located at a highway in- <br /> 1 /©1 i tersection, show the intersecting high- <br /> 12— ways and the setbacks required along I <br /> them and at the intersection. <br /> PERMIT FEES <br /> d`� <br /> '� Subdivision $15.00 <br /> 1.00 <br /> Co <br /> r Land Use <br /> K Building 5. oil ► <br /> z. <br /> Sanitary ii •ii• <br /> NC <br /> /'f �� , Well 5.00 0) <br /> V.1)0 4., . ' Li Septic Tank 10.#1 � .� 8 <br /> Combination Building, Sanitary <br /> 1 <br /> and Well 15.00 n <br /> Pei ire Privy 5.00 "(es <br /> . .. 4 <br /> k-„,. .1,,, <br /> `41 <br /> '..(J-4-02/ <br /> Signature of Owner or Agent Da e Z ing �.:` inistrator <br /> Inspection Date /— a O Inspector <br /> / <br /> Remarks 0../r.. -ini„."--,t,../ <br /> 1 <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 />