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Burneii County ((( `_ + Office of Zoning Administrator 1 -o o H z <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 • <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a = ! o Q <br /> Permit for the work described and located as shown herein. The undersigned agrees that all N <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, m <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- -o a 'jLi 'kj: \. <br /> lations of the State of Wisconsin. � a • <br /> h G A. O <br /> . ,. d riw./r-� - <br /> Owner or Agent (please print) Contractor or Surveyor y ~� `D <br /> i It <br /> Address Address a <br /> Phone Phone 0 <br /> 41)--"4—.. <br /> . k. i )k.. N qi) <br /> Pluer Well Driller • Zr <br /> 0 <br /> Address Address m GI ,tt' <br /> o r+ <br /> Phone Phone CD y m <br /> 0 r, 0 <br /> CD o ''' <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: ( ° -oType of Cortgruction No. Bathrooms z z o <br /> 1. Work . .c..St,}V 4-. .`')I No. Bedrooms — ° o CD <br /> New Building Size ft. x ft. Septic Tank Size Gals. (/) <br /> Addition Height Stories /a C 6 r <br /> Sanitary . .L Area 7a.Absorption Field Site: C, <br /> � <br /> Filling Soil Type _4 o <br /> `-'v h Slope <br /> 5. Permits Required <br /> Grading Subdivision Perc. Rate �.• Jr" <br /> Mobile Home Sanitary 4.-4---" Dry Well CD <br /> Privy Building Seepage Trench CD <br /> Well Well Privy i fa �. <br /> Subdivision Other (Specify) Seepage Bed ,.tx3 b <br /> Conditional �C.1) N <br /> 2. Classification Land Use ! a' CD <br /> Zoning Dist. !, ° o <br /> 6. Use (describe exact) 1 fam H' <br /> 3. Lot Size home, motel, etc.) FOR COMMERCIAL USE — ° <br /> ft. x ft. Plans Submitted <br /> a oje L.c. .tT. . sq. ft. Plans Approved <br /> Fig. A. Location of proposed structures and <br /> existing structures, well, sewage sys- o <br /> tems, roads, etc., should be sketched m <br /> in Fig. A. Include road setback, side <br /> and back yard dimension and location -Es' <br /> and setback from all bodies of water. ,.. <br /> If property is located at a highway in- ;' 6"lj <br /> tersection, show the intersecting high- <br /> ways and the setbacks required along <br /> them and at the intersection. <br /> po <br /> 1 0 <br /> PERMIT FEES = <br /> Subdivision $25.00 + $2.00 per lot. fD <br /> Land Use $10.00 0 ! • <br /> B n 10.00 0 <br /> e 10.00 g..) <br /> Septic Tank 10.00 t <br /> Privy 5.00 V <br /> 1 <br /> 1 V <br /> %I \ <br /> Si .tu • of Owner or Agent //hi/ <br /> D A <br /> di:C ,/ <br /> Zoning Administrator. . <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 />