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Burnett County • - Office of Zoning Administrator N o H z <br /> CD CD d 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT -o - CD <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a '-' o ...I <br /> Permit for the work described and located as shown herein. The undersigned agrees that all d N <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, X- C t : <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- -o °- <br /> lations of the.Statgr-e,j1r <br /> f Wisconsin. CD a '�. <br /> 0 <br /> Datx14 / _. , r <br /> .+ m ` o <br /> Owner or Agent (please print) Contractor or Surveyor y m <br /> ;I ~ LAZia C�7 rc) de 'QJ� m a. t.. <br /> Address Address <br /> a <br /> Phone Phone . A, <br /> f <br /> 3 ......k.) <br /> Plumber Well Driller <br /> r n R) o <br /> Address ' Address �i /'� \' 0 0 A <br /> �3 �� n ° ! fly rt U <br /> Phone Phone \ m o 0 <br /> M <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: / -6 <br /> Type of Canstu,iction No. Bathrooms ,'o z oa <br /> 1. Work •—k, l S l I ' No. Bedrooms 0_— ,- • ° <br /> New Building Size ft. x ft. Septic Tank Size Gals. - '�. .� <br /> Addition Height Stories 7SQ. i, ti kJ <br /> 1 <br /> Sanitary ( " Area 7a.Absorption Field Site: )..) ti <br /> Filling Soil Type U 4 o <br /> e <br /> Moving 5. Permits Required Slope i & <br /> Grading Subdivision Perc. Rate r <br /> Mobile Home Sanitary Dry Well a � <br /> Privy Building Seepage Trench CD 'r t n <br /> i fa <br /> Well Well Privy [/ <br /> Subdivision Other (Specify) Seepage Bed f.0 . 7 � uN M <br /> Conditional \° .1' c CD <br /> 2. Classification Land Use or n <br /> Zoning Dist. R °'? a o <br /> A 4 6. Use (describe exact) , 1 fam. < y' <br /> 3. Lo Size home, motel,etc.) FOR COMMERCIAL USE 6. 111—a. <br /> 1.0 0 ft. x II d ft. Plans Submitted J` <br /> sq. ft. Plans Approved I,t, <br /> Fig. A. /0- Location of proposed structures and n' —I <br /> existing structures, well, sewage, sys- o <br /> tems, roads, etc., should be sketched <br /> /4 <br /> in Fig. A. Include road setback side ! <br /> ffkilM L O and back yard dimension and location <br /> ` Li/v.1. and setback from all bodies of water. <br /> If property is located at a highway in- <br /> N tersection, show the intersecting high- <br /> �' ways and the setbacks required along <br /> is- _], them and at the intersection. <br /> vv�� m <br /> PERMIT FEES <br /> J Subdivision $25.00 + $2.00 per lot. `D <br /> Land Use $10.00 co <br /> • i-1-1I Building 10.00 '.,, <br /> (, '- <br /> Pr <br /> anitaF0 35.00 "1 <br /> Well 10.00 <br /> Privy 5.00 <br /> w A 3,j.ad <br /> 4 <br /> G "-, /9/2 <br /> Signature ofof Owner or Agent Date �AZoning Administrator <br /> Inspection Date 4 - / C' ^ �// '� Inspector/ i` -'l QJ�<<" -« <br /> Remarks ' / l ,lir C- -e-7--/—&- ~ <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 />