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Burnett County • ' Office of Zoning Administrator o z <br /> CD CD APPLICATION FOR SANITARY '— LAND USE — BUILDING PERMIT -- 3 r, <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a H - i o U\ <br /> Permit for the work described and located as shown herein. The undersigned agrees that all taa y (1 <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, A- CD \\' <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- -o a <br /> lations of the State of Wisconsin. CD a b <br /> •,�/IL DDFO . . , cieg-Fgr- tu <br /> �. <br /> Owner or Agent (please <br /> f print) //' Contractor or Surveyor c CD <br /> -! <br /> Pf <br /> ri <br /> a. <br /> Address Address a D <br /> co <br /> NI <br /> Phone Phone 3c f <br /> UI vU lFn,4sv# <br /> Plumber Well Driller \C \ <br /> Z) <br /> 7R- ( -L )&L3SST R j /s <br /> Address <br /> Address o G) • <br /> 166— 73' 3 '"� <br /> Phone Phone k Tv, r <br /> c) .. 0 <br /> . CD o ti <br /> DESCRIPTION 4. BuildingDetails -o <br /> 7. Sanitary Facilities: .. -o <br /> Type of Construction No. Bathrooms l z z o <br /> 1. Work No. Bedrooms <br /> New Building Size ft. x ft. Septic Tank Size Gals. �J r' :U <br /> Addition Height Stories / <br /> Sanitary ,`. . Area 7a.Absorption Field S'te: V <br /> Filling Soil Type . . " NZ, P o <br /> Slope 4 . <br /> Moving 5. Permits Required / <br /> Grading Subdivision Perc. Rate 1 <br /> Mobile Home Sanitary ,', Dry Well CD 7p <br /> Privy Building Seepage Trench CD b1 <br /> Well Well Privy <br /> Subdivision Other (Specify) Seepage Bed /2 s A .r.S-O G'r ,_'`,� <br /> Conditional \� cn cn <br /> 2. Classification Dp Land Use ��Q a `� h <br /> Zoning Dist. 2).z1.°. . RTR ° o' <br /> Kd 6. Use (describe exactly, 1 -fam. V y a <br /> 3. Lot Size home, motel,etc.) FOR COMMERCIAL USE o <br /> a 1V <br /> ft. x ft. / f i /I Plans Submitted 1 ` <br /> sq. ft. [ m-O/ Plans Approved W <br /> Fig. A. Location of proposed structures and <br /> existing structures, well, sewage sys- o <br /> • --�E�� tems, roads, etc., should be sketched t' <br /> CAarti , in Fig. A. Include road setback, side 3 <br /> R N and back yard dimension and location >` o- <br /> and setback from all bodies of water. T <br /> �/ If property is located at a highway in- <br /> Ktersection, show the intersecting high- <br /> I i5' /50 <br /> ways and the setbacks required along <br /> \ >, them and at the intersection. <br /> c. <br /> I 1`-- PERMIT FEES <br /> CC <br /> de------ 60I MI Subdivision $25.00 + $2.00 per lot. Co <br /> 6E,re FANv< Land Use $10.00 <br /> � SF�,>o�6E Q� Build' • 10.00 �� <br /> M l 0 p 7 r 75(� ,�f},G t_ 3105.00 <br /> /2, r / D Well .00 <br /> �( 35 is , e0NettEr Privy 5.00 <br /> t <br /> g(.44.74J/&,/Y./7 a•rO(2ae—iea4t) 4,14/ 7 <br /> ignature of Owner or Agent Date Zoning Administrator <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. <br />