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'. <br /> Burnett County Office of Zoning Administrator o !� <br /> APPLICATION FOR SANITARY — LAND. USE,— BUILDING PERMIT ° ��� <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a -1 " o <br /> Permit for the work described and located as shown herein. The undersigned agrees that all m y " <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, a, — I Q( <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- - a 1 (� <br /> lations of the State of Wisconsin. fD a Li <br /> g .,,....k <br /> 0 r d M.Q, L'i't i\-, 63'/C_ irS 0 i-N. ri:7 P1'1. "e--% 3 Eu <br /> et CD <br /> Owner or Agent (please print) Contractor or Surveyor (.7) <br /> m 11 <br /> Address Address a <br /> Phone Phone <br /> Plumber . /4...fr, n c '''N..---, 0.., <br /> Well Driller i 'V! <br /> Af V o <br /> Address Address m G) `- <br /> : 1 ri o <br /> n <br /> Phone Phone H m <br /> (D 0 " <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities -v '" <br /> Type}�o-f Construction No. Bathrooms 1 z z o <br /> 1. Work �/ ! jr.Cr re," Dishwasher �� ° CD <br /> New Building Size . . q ft. x .q i ft. Garbage Grinder <br /> Addition ,V` Height Stories Autom. Laundry /� <br /> Sanitary Area No. Bedrooms <br /> Alterations Waste Disposal System VJ ° <br /> Moving 5. Permits Required Septic Tank Size Gals. <br /> J <br /> Wrecking Subdivision .. Absorption Field Site J <br /> Mobile Home Sanitary Cl Soil Type . ` 4.Z. !'4 .9. . . . . CD Co 9) <br /> Privy . . ._./ Building . .✓ Slope 9. . C9. . ..5.4 CD CD <br /> + <br /> ir <br /> Well Well Perc. Rate <br /> Subdivision Other (Specify) Dry Well o ( {A <br /> Conditional Seepage Trench N N <br /> 2. Classification Pu.� Land PrivycZoning Dist. Seepage Bed I .8�. .r• CD <br /> ...• o <br /> 6. Use (describe exact) 1 -fam. — <br /> 3. Lot Size home, .tel,etc.) _ FOR COMMERCIAL USE ° <br /> D <br /> ft. x ft. Plans Submitted <br /> a(,), e O Plans Approved , ~ <br /> /\. Fig. A. Location of proposed structures and ..° <br /> existing structures, well, sewage sys- o <br /> \ ' l , tems, roads, etc., should be sketched - '? = <br /> "/ " �I in Fig. A. Include road setback, side ' <br /> \ , o and back yard dimension and location r -o <br /> y t✓ and setback from all bodies of water. <br /> If property is located at a highway in- <br /> tersection, show the intersecting high- <br /> �� ways and the setbacks required along C <br /> them and at the intersection. <br /> $c <br /> q 7. <br /> Po' Jo C / PERMIT FEES a, <br /> ao <br /> Subdivision $15.00 co <br /> Land Use 1.00 <br /> Building 5.00 <br /> r Sanitary 10.00 <br /> �{0 Well 5.00 <br /> , ,iQa Septic Tank .00- <br /> • <br /> Combination Building, Sanitary - <br /> and Well 15.0s <br /> kL •. / �./� .. . .. . . ... . . .. . .. <br /> gnature of Owner or Agent Date Z ing A inistrator <br /> Inspection Date 7- a [- 7 / Inspector es-. <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 />