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Burnett County e O fice of Zoning Administratorcf) G <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT �. 3 f;' —I Q <br /> ? • <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a -I '' o a <br /> Permit for the work described and located as shown herein. The undersigned agrees that all d N A <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, x- m C <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- v a <br /> lations of the State of Wisconsin. O <br /> /6 4-ir-e A...1 c, tk.t se r 1 I...- rt * <br /> 4+ <br /> Owner or Agent (please print) Contractor or Surveyor y `�° <br /> y� ° in/ 6 0 Cl ' /70 tsi a t-- �' n 4- <br /> -Address Address a 0 7 ,G <br /> e 4, -e,.,.-. /42/I �=, ti , C-. �/ 7 C <br /> ,.- • <br /> 63 Phone Phone i <br /> R. 14-erlt <br /> Plumber Well Driller <br /> Address Address <br /> °` <br /> �! o < <br /> G <br /> Phone Phone ,'„ r- <br /> f)CD r, o <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: j ° <br /> Type of Construction No. Bathrooms z z E <br /> 1. Work t- i Q ry' ' No. Bedrooms "� 9 ° 73 m 7 J3 <br /> New Building . .t.—,-- Size a 4 ft. x (r-* ft. Septic Tank Size Gals. moo <br /> Addition Height Stories ) F <br /> Sanitary Area 7a.Absorption Field Site: _ <br /> Filling Soil Type 55B.....Q , <br /> Moving 5. Permits Required Slope I <br /> Grading Subdivision Perc. Rate <br /> Mobile Home Sanitary C------ <br /> ._— Dry Well m m 1. <br /> — CD C <br /> Privy Building L—� Seepage Trench r 1T} <br /> Well Well '---- Privy <br /> Subdivision Other (Specify) Seepage Bed /.y.l'ol I o° `— <br /> o <br /> Conditional p cn N <br /> 2. Classification Land Use I O cr <br /> a <br /> Zoning Dist. !� o <br /> 6. Use (describe exactly-fam. Ey N ' <br /> 3. Lot Size home, motel,etc.) —`� FOR COMMERCIAL USE ° <br /> C <br /> l U �' ft. x LI C1 U ft. Plans Submitted af <br /> ~ <br /> sq. ft. Plans Approved - (-- �V <br /> c <br /> Fig. A. Location of proposed structures and <br /> existing structures, well, sewage sys- o <br /> tems, roads, etc., should be sketched F C, <br /> in Fig. A. Include road setback, side 3 <br /> (IC* c� and back yard dimension and location ? •o' <br /> and setback from all bodies of water. 'r <br /> (� �T r <br /> If property is located at a highway in- 6i / 4i tersection, show the intersecting high- -_ <br /> `'-'7- > ways and the setbacks required along <br /> them •and at the intersection. `� <br /> .c,'�a'— <br /> \�rii'' E_�^ / e J, f c �Y�*►^'f ER M I T FEES <br /> co <br /> Use 1.00 <br /> Building 5.00 '�- <br /> Sanitary 10.00 Cl <br /> Well 5.00 <br /> Septic Tank 1.00 <br /> CC- <br /> Combination Building, Sanitary <br /> and Well 15.00 <br /> Privy 5.00 <br /> r- <br /> 1C� 1 77 81 . . <br /> r� <br /> Signature of/ wnerorAgentoate A <br /> ng Ad nistrator <br /> r <br /> Inspection Date ' l Inspector l <br /> Remarks © IS- <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 />