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Burnett County z23t� Office of Zoning Administrator��� N , o <br /> CD CD y 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT -o' - CD <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a -I rt o <br /> Permit for the work described and located as shown herein. The undersigned agrees that all c''' <br /> -h <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, A- cVY <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- v a <br /> lations f the State of Wisconsin. - o_ r, 0 <br /> �t�T. / v1/ryl�,r1 D 5co <br /> `�. E. <br /> Owner or Agent (please print) Contractor or Surveyor N CD <br /> ( �p <br /> • h Address1 �� � Address a N' (\'1 <br /> Phone 4 Phone <br /> NI <br /> Plumber Well Driller <br /> Address Address m G <br /> 0 o <br /> r* < <br /> o ,. <br /> Phone Phone co rt or <br /> CD o <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: V <br /> IType of Construction No. Bathrooms Z o z <br /> 1. Work WO9/?t7' • No. Bedrooms . .r ° CD <br /> New Building Size .RO ft. x .` ,..)..1., ft. Septic Tank Size Gals . . 7,1-U . (I) <br /> Addition . . .X,, Height . .gi . Stories . . I. . . ✓�` . .S/..- L- <br /> 7a.Absor tion Field Site: <br /> Sanitary Area 4� �' p �` � �l' <br /> Filling Soil Type r�� O o <br /> Moving 5. Permits Required Slope \ ' <br /> Grading Subdivision Perc. Rate T) <br /> Mobile Home Sanitary Dry Welt CD CD <br /> Privy Building )\ Seepage Trench fD CD <br /> Well Well Privy <br /> Subdivision Other (Specify) Seepage Bed o V <br /> Conditional <br /> o • N cn <br /> c co. <br /> 2. Classification Land Use a `1 a '* <br /> • <br /> Zoning Dist. `r f,) Z o <br /> 6. Use (describe exactly, 1 -fam. V l <br /> 3. Lot Size ome motel,etc.) FOR COMMERCIAL USE o <br /> c <br /> ft. x ft. Plans Submitted CA <br /> 40/e . . . . sq ft. Plans Approved •_ <br /> Fig. A. Stj taw,- Location of proposed structures and —i <br /> existing structures, well, sewage sys- 0 <br /> tems, roads, etc., should be sketched (.Y <br /> in Fig. A. Include road setback, side _. <br /> and back yard dimension and location C�a <br /> and setback from all bodies of water. 0\1 <br /> If property is located at a highway in- 1 <br /> } .• tersection, show the intersecting high- <br /> .." <br /> 1Ni ways and the setbacks required along r uj <br /> ,7�� _ `�� *—____ IF ly S115?) them and at.the intersection. <br /> PERMIT FEES ,._/ v <br /> b‹.---DW Subdivision $15.00 co <br /> fD <br /> r <br /> 1 1 Land Use 1.00 <br /> // � Q/� Building 16 -h!** V <br /> fe� '°I�" Sanitary 10.00 <br /> Well 5.00 • <br /> Septic Tank 10.00 <br /> Combination Building, Sanitary <br /> rtf and Well 15.00 <br /> Privy 5.00 <br /> LO �-�.� ,w�. . r — l— t :6?..z.; .-e . <br /> Owner or gent Date Zon. Administrator <br /> Signature <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 />