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Burnett County Office of Zoning Administrator ( i �-CioV <br /> 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT a - <br /> CD <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a o <br /> Permit for the work described and located as shown herein. The undersigned agrees that all y -I, ! :, <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, Q <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- v o_ <br /> lations of the State of Wisconsin. co a <br /> coom � O <br /> �NsNCO t�rlN �iN.br"Y 9 �N,¢ecEs �`kON We3 <br /> Owner or Agent (please print) Contractor or Surveyor N 1Etz,* <br /> D <br /> Address eas7eR ( �,,Jrsc . • <br /> S` -, P• Sits �i.e/A1, Address �" <br /> Apia- city! — 4 Vo0 "0 <br /> Phone Phone i <br /> ro <br /> Plumber ''‘NI <br /> Driller <br /> 0 <br /> Address Address C) >' <br /> o o <br /> °. ,- <br /> Phone Phone CD y r <br /> 0 r, 0 <br /> CD ° <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: a <br /> Type of Construction No. Bathrooms t z Z o <br /> 1. Work VociD fRAne No. Bedrooms 4. . ° ° a <br /> }) <br /> New Building Size . /.a. ft. x 40 ft. Septic Tank Size Gals. 75.0 -- <br /> Addition . . . . Height Stories . . . . . :E <br /> ` <br /> Sanitary Area . . . . a u4).Ai... �!' 7a.Absorption Field Site: N <br /> Filling Soil Type 1_ 4 r <br /> 0 <br /> Moving 5. Permits Required Slope <br /> Grading Subdivision Perc. Rate , T <br /> Mobile Home Sanitary Dry Well <br /> Privy Building }S Seepage Trench CD CD k _ rT.) <br /> Well Well Privy •Subdivision Other (Specify) Seepage Bed r o <br /> Conditional Lk) cn cn <br /> co <br /> 2. Classification Land Use ) a <br /> Zoning Dist. eg—� Q ° .4 <br /> <' 6 <br /> 6. Use (describe exactly, 1 -fam. <br /> 3. Lot Size home, motel,etc.) FOR COMMERCIAL USE (. o <br /> i'0O ft. x 9OO ft. ' //� P ns Submitted <br /> sq. ft. tans Approved _� `�i <br /> iin <br /> Fig. A. Location of proposed structures and <br /> 1. 4 jrZc existing structures, well, sewage sys- `. C o <br /> tems, roads, etc., should be sketched 0 <br /> in Fig. A. Include road setback, side a` 0- <br /> �r and back yard dimension and location -a' <br /> 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 1�. <br /> 3S �'v' egES ' 1e 25 -+ them and at the intersection. l ���) :�% <br /> S` I o <br /> 111 <br /> PERMIT FEES ° <br /> CM <br /> Subdivision $15.00 CD <br /> Land Use 1.00 <br /> •1 Building <br /> 44pir.„4/ Sanitary 0�0 <br /> Well 5.00 <br /> Septic Tank 1.00 <br /> �5ePT'C Combination Building, Sanitary <br /> :3i!'sreAt and Well 15.00 <br /> I Privy 5.0 <br /> ) <br /> 1 <br /> C-3,CLtl:,,...-ge:A-4 j./_(--:?____ 77 r? ,_ <br /> Signature of Owner or Agent Date Zoni g Ad nistrator <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 he made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />