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Burnett County Office of Zoning AdministratorCD CD 0 0 <br /> o �- <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT a CD <br /> - TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application fora 0 o <br /> Permit for the work described and located as shown herein. The undersigned agrees that all <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, CD N <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- v a :\i <br /> lations of the State of Wis sin. _ 3 ° O <br /> .�.0 12�:�Y . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . " - � <br /> Owner or ent please print) Contractor or Surveyor N \ `; <br /> 7. . . . . . . . . <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Ad ress Address a <br /> Phone Phone <br /> 5. . . . . !o 7. �. . . . . . . . S e_I f': . . . . . . . . . . . . . . . . . . . . . <br /> Plumber Well Driller. <br /> . . . .�Si �. . . . . . . . . . . . . . . <br /> Address Address ) CD O <br /> Phone Phone CD H m <br /> ° r\ <br /> CD o - <br /> DESCRIPTION 4. Building'Details 7. Sanitary Facilities v <br /> Type of Construction No. Bathrooms a�-?— z z o <br /> 1. Work . . . . . . . . . . . . . . . . . . . . . . Dishwasher ° °� � <br /> New Building Size . . ft. x f Garbage Grinder <br /> Addition . . . . . . Height . . . . . Stories Autom. Laundry <br /> Sanitary �w . �✓. . . Area 0`�.2. . . . . . . . . . . No. Bedrooms <br /> Alterations . . . . . . Waste Disposal System :�y, ° <br /> Moving . . . . . . 5. Permits Required Septic Tank Size Gals. <br /> Wrecking . . . . . . Subdivision . . Absorption Field Site : <br /> M T <br /> Mobile Home . . . . . . Sanitary . . �. Soil Type . . . . . ... . . �n m <br /> CD CD <br /> Privy . . . . . . Building ✓. . Slope . . . . . . . . .c? 2o. . . . . . . <br /> Well K . . Well Perc. Rate . . . . 3. �. . . . . <br /> Subdivision . . . . . . Other (Specify) . . o Dry Well . . . . . . <br /> Conditional . . . . . . Seepage Trench N <br /> CD <br /> 2. Classification Land . . . . . . Privy <br /> Zoning Dist. . . . . . . Seepage Bed o <br /> 6. Use (describe exactly, 1 -fam. I N' <br /> 3. Lot Size home, motel,etc.) FOR COMMERCIAL USE :�. 0 <br /> o <br /> fit — . . . . . . ft. _���� h Plans Submitted . . . . . . <br /> 1 Q.0� 1�. <br /> -rf3. . . . . . . . . . sq. ft. I y Plans Approved . . . . . . ; ', 'f1 j <br /> I <br /> ----------------------------------------------------------------- <br /> Fig. A. Location of proposed structures and O <br /> existing structures, well, sewage sys- ° <br /> Ntems, roads, etc., should be sketched <br /> in Fig. A. Include road setback, side3 <br /> and back yard dimension and location t' -a <br /> and setback from all bodies of water. <br /> If property is located at a highway in- <br /> tersection, show the intersecting high- ' ' N <br /> : a <br /> Qways and the setbacks required along <br /> / them and at the intersection. :J� <br /> - au3¢ PERMIT FEES <br /> lu}a S'+e Subdivision . . . . . . . . . $15.00�1 <br /> `� • - Land Use . . . . . . . . . . . 1.00 <br /> O s � r Building . . . . . . . . . . . 5 00 � N <br /> Sanitary 9, <br /> a <br /> Well . . . . . . . . . . . <br /> iJ Septic Tank . . . . . . . . ail. <br /> Combination Building, Sanitary C <br /> s and Well . . . . . . . . 15.OQ` <br /> 1 4 <br /> nn - <br /> o. W jo^J JR <br /> • •...................... ......... .... ..............�•.••........... •.Y. ........�{............. .... •. .` •. • ...•...•.......• <br /> Signature of wner or Agent Date /� nii min.(strator <br /> Inspection Date2' ..G.'........<...<..-1... Inspector � � . .......�'�- . ............................r . ....................... .... .. . .... <br /> Remarks CCU <br /> ......�- ... �....... .... a <br /> ................................ ......O.L4-...... <br /> .... <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 />