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/V), <br /> Office of Zoning Administrator / <br /> Bu"rnett County 9 LJ� o 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a H 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, m 1 -� <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- <br /> lations of the State of Wisconsin. 3 d v} O <br /> . . . . . . . . . . . . . . . . <br /> . <br /> Owner or Agent (please print) / Contr. . actor. . . or. . .Surve. Yor C <br /> Y�.�� . .Wr hi S �G2 l/ iSL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> m <br /> Address Address +\ sA <br /> 2-7;_73 7 — <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ;t <br /> Phone . . . . . . Phone <br /> '�.® ✓ . . . . . . . . . . € U� y <br /> Plumber Well Driller <br /> . . . . . . . . . . �s . o <br /> Address Address <br /> . <br /> Phone Phone � <br /> m p <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: <br /> T e of C�Tr,��tion No. Bathrooms -�� Z Z o <br /> 1. Work 'J` rs o o <br /> . . . . . . f. �l?F1�.5-4'!L: No. Bedrooms <br /> New Building . . . . . Septic Opp V <br /> . . . . . Size ft. x . . . . . . ft. Se tic Tank Size Gals. �. . . . S ; - <br /> Addition Height . . . . . Stories . . . . . . • • . . . . Erg <br /> Sanitary Area . . . . . , , • , . . . , - , . . . . 7a.Absorption Field Site: <br /> Filling Soil Type . . . . T�<?'t!'�--. . . . . . . �(j ;(,0 ; o - <br /> Moving . . . . . . 5. Permits Required Slope . . . . . . • ' ' ' ' <br /> Grading . . . . . . Subdivision Perc. Rate . . . . . . . . . . . . . . . � � T <br /> Mobile Home . . . . . . Sanitary Dry Well . . . . . . C. M M <br /> Privy . . . . . . Building , , , , . . Seepage Trench . . . . . . <br /> Privy <br /> Suebldivision . . . . . . Othler (Specify) . . . . . . Seepage Bed <br /> �nI Conditional . . . . . . � -.� ( m <br /> 2. Classification9t�z4 Land Use S a <br /> Zoning Dist. (!� o' <br /> N 6. Use (describe exactly, 1 -fam. n '^ <br /> 3. Lot Size home, motel, etc.) FOR COMMERCIAL USE •�' 0 :N <br /> ft. x ft. Plans Submitted <br /> sq. ft. Plans Approved .T—.p :f\ <br /> ------------- ----------- P------- ----- <br /> Fig. A. Location of proposed structures and <br /> existing structures, well, sewage sys- o <br /> tems, roads, etc., should be sketched <br /> in Fig. A. Include road setback, side :� s <br /> and back yard dimension and location o' <br /> and setback from all bodies of water. \. <br /> If property is located at a highway in- <br /> tersection, show the intersecting high- <br /> ways and the setbacks required along <br /> them and at the intersection. <br /> PERMIT FEES til <br /> Subdivision . . . . . . . . . $15.00 tD <br /> Land Use . . . . . . . . . . . 1.00 <br /> Bu iIdin . . . . . . S . . 5.00 �• <br /> anitar �d'�. �-9-BB <br /> Well . . . . . . . . . . . 5.00 <br /> Septic Tank . . . . . . . . . 1300 V <br /> Combination Building, Sanitary <br /> and Well . . . . . . . . 15.00 <br /> Privy . . . . . . . . . . . . 5.00 <br /> 7- <br /> i <br /> Signatu re,[o�f Owner or Agent Date Zoning <br /> Inspection Date .�J.".a2//�,, :-//. y.5........................ Inspector ................................................................................................ <br /> Remarks .G.�i?:/T.6. L:`L"""'�'1'� <br /> ..................................................................................................................................... <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 />