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Burnett County Office of Zoning Administrator <br /> oCD ID 0 <br /> 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ° 3 CD <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application fora = o <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, i <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- v °- (` <br /> lations of the State of Wisconsin. I m :� Ov <br /> Owner or Agent (please print) Contractor or Surveyor <br /> N <br /> 44. 6—,t CD <br /> CD <br /> Address Address <br /> CD <br /> Phone Phone <br /> Plumber Well Driller ' <br /> Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> °o. <br /> . . . . . . . . . . . . . <br /> Phone Phone N 0 <br /> o <br /> :T <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: <br /> Type of Constru tion No. Bathrooms • • • •�• • ° o ° <br /> 1. Work No. Bedrooms . . . . . . CD <br /> New Building Size . . . . . ft. x . . . . . . ft. Septic Tank Size Gals. <br /> Addition . . . . . Height . . . . . Stories . . . . . . 7T N ? Q <br /> Sanitary .4____-1Area 7a.Absorption Field Site: <br /> Filling . . . . . . <br /> Soil Type . . . .� � \ �� o <br /> Moving . . . . . . 5. Permits Required Slope . . . . . . . . . . . <br /> Grading . . . . . . Subdivision + ` <br /> Perc. Rate . . . . . . . . . . . . . . . . . "I <br /> Mobile Home Sanitary V. Dry Well . . . . . . m M <br /> Privy . . . . . . Building • • . • • • Seepage Trench . . . . . . : T <br /> Well . . . . . . Well • • , • , , Privy \ <br /> Subdivision . . . . . . Other (Specify) . . . . . . Seepage Bed d-Xd <br /> Conditional . . . . . . :� c CD <br /> n <br /> 2. Classification Land Use . . . . . . , Z a o' <br /> Zoning Dist. . . . . . . < <br /> 6. Use (describe exactly 1 -fam. H' <br /> 3. Lot Size home, motel,etc.) FOR COMMERCIAL USE ° <br /> ( . . ft. x . . . . . . . . ft. Plans Submitted <br /> sq. ft. Plans Approved <br /> ----------------------------------------------------------------- <br /> Fig. A. Location of proposed structures and <br /> existing structures, well, sewage sys- o <br /> tems, roads, etc., should be sketched <br /> ° <br /> in Fig. A. Include road setback, side 3 <br /> oTand back yard dimension and location A <br /> and setback from all bodies of water. <br /> kJV'Qlf property is located at a highway in- 1C <br /> tersection, show the intersecting high- ;\ <br /> t i ways and the setbacks required along <br /> ►��� them and at the intersection. <br /> � `,, �/ate. �' PERMIT FEES <br /> 4 ( 'J <br /> Lo <br /> Subdivision . . . . . . . . . $15.00 `D <br /> Land Use . . . . . . . . . . . 1.00 <br /> Building � <br /> Sanitary . . . . . . . . . 0 <br /> Well . . . . . . . . . . . 00 ty, :tS <br /> f Septic Tank . . . . . . e <br /> Combination Building, Sanitarand Well . . . . . . . . <br /> Privy . . . . . . . . . . . . 5.00 <br /> ........... ...l.:.y........'.Y..u...... ..... ... .. .// c . ...... <br /> Sig ature of Owner or Agent Q Dat ping m-Inistrat,0rrr <br /> InspectionDate ............... ........... Inspector ...........,....................^:................................................. <br /> ol <br /> Remarks ....... ........................ <br /> ....................................................................................................................Y.......................................................................... <br /> ................................................................................................................................................................................................ <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 />