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Burnett County Office of Zoning Administrator c'� r� �, (..g....., <br /> ' - ' CD CD CD o <br /> APPLICATION FOR SANITARY — LAND USE -BUILDING PERMIT -0 , CD <br /> _. <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a -I - \ * <br /> Permit for the work described and located as shown herein. The undersigned agrees that all ED H 1 <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, C C/3 <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- o- \ <br /> lations of the State of Wisconsin. 3 o <br /> O <br /> 2. eke .$si D it S i4CJ SMtD <br /> Owner or Agent (please printl Contractor or Surveyor — <br /> c <br /> Address Address a Q R. <br /> Phone Phone ( C9+ <br /> 1U L Io Fer_ W L. <br /> P umber Well Driller x i C <br /> Address ! Address ^ h o <br /> �'W o' U <br /> Phone Phone , C - o t <br /> ° .. C <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: •° <br /> Type of Construction No. Bathrooms • .I. . o Z V' <br /> a 0 <br /> 1. Work No. Bedrooms ° CD Zi <br /> New Building Size ft. x ft. Septic Tank Size Gals. . .!ZOO bi <br /> Addition Height Stories . !•''�• <br /> Sanitary Area 7a.Absorption Field Site Q Z r <br /> Filling Soil Type . , `' o <br /> Moving 5. Permits Required Slope _ ( <br /> Grading Subdivision Perc. Rate . I <br /> Mobile Home Sanitary ' Dry Well `�, - C <br /> Privy Building Seepage Trench ; `D C <br /> Privy jj ift Well Well . .} - o <br /> Subdivision Other (Specify) Seepage Bed o Cl) N <br /> Conditional ° CD <br /> 2. Classification Land Use I a 0 <br /> • <br /> Zoning Dist. w 0 <' S <br /> 0 <br /> 6. Use (describe exact) I N. <br /> 3. Lot Size �� home, motel,etc.) FOR COMMERCIAL USE ° <br /> ,P..7.0. . . ft. x ft. Plans Submitted 0 ' CA <br /> sq. ft. Plans Approved � <br /> .4-„,, 4 <br /> i\ c- _ 'JZ Nrq ____� Location of proposed structures and -i <br /> �o / -..,, existing structures, well, sewage sys- <br /> tems, roads, etc., should be sketched 7 <br /> r., in Fig. A. Include road setback, side () ` <br /> C1 f/J and back yard dimension and location <br /> �+' <br /> A��� <br /> �Qi?R�� / and setback from all bodies of water. \ <br /> If property is located at a highway in- ti C" (1\ <br /> tersection, show the intersecting high- <br /> ways and the setbacks required along N4 <br /> 4 S7o them and at the intersection. (30. <br /> N �OLD <br /> LYg <br /> . PERMIT FEES <br /> V Subdivision $15.00 l' `D <br /> Land Use 1.00 <br /> e� �L- el:y <br /> LI Building aI <br /> �� <br /> ������ Sanitary 10.0� ...? \iqy 4> <br /> ' 7F Well .00 <br /> I Septic Tank 10.00 <br /> f3L 1" A Combination Building, Sanitary <br /> 1Cd and Well 15.00 <br /> 4•1 \ Privy 5.00 <br /> or <br /> Sfi4 "7a - <br /> /2 <br /> a/6'7 �. <br /> . tdeizocd <br /> Signature of caner or Agent D e ing inistrato <br /> 42./L <br /> Inspection Date 6 7 �s� Inspector � ... . .... <br /> Remarks <br /> ,....)Cer..,....4_.„ a___, „el)..,..,I,2"/,,,,i„,, /6p-A-f 6 at,c2_,TA <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 />