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Burnett County Office of Zoning Administrator ' o ---1 z <br /> CD m d o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT °, 3 <br /> 7 <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 <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, 77 m <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- _0 ° \\Vr <br /> lations of the State of Wisconsin. 3 O <br /> r 3T <br /> 4f- �.r. l .l. . . . . . . . . . . . . . . . . . . . . . . V. . . . . . . . . _ — <br /> c <br /> Owner Or ent ( lease print r�l Contractor or Surveyor <br /> Address Address a \ rS <br /> .o. .l r.� . . . . �i.h n . . . .s . 3 a 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> one.� Phone <br /> . . <br /> Pludr Well Driller \� <br /> O <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . n• o <br /> Address Address 0 0 <br /> . . . . . . . . . . . . . <br /> Phone Phone <br /> r <br /> o o -� <br /> o `I <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: <br /> Type of Construction No. Bathrooms • • . o z -00 <br /> 1. Work �. !'a �.�. . . . . . No. Bedrooms / ^ <br /> o <br /> New Building . . . 41/Size v ft. x ft. Septic Tank S//iz''--e��Gals, . . . . . . < :V d <br /> Addition Height . . . . . Stories . . . . . . e°� f •d ='�\`� <br /> Sanitary !/ Area . . . . . . . . . . . . . . . . . . . 7a.Absorption field Site: V k <br /> Filling . . . . . . Soil Type . . . . . . . . . . . . . . . . . . o <br /> 5. Permits Required SlopeMoving . . . . . . <br /> Grading . . . . . . Subdivision . . . . . . Perc. Rate 1. :( A <br /> Dry Well m - <br /> Mobile Home . . . . . . Sanitary C� A <br /> Privy / Building Seepage Trench _ 1 ,11 <br /> Well C/ Well 41 Privy 0 N <br /> Subdivision . . , , , , Seepage Bed �. 'oo N <br /> . . . . . Other (Specify) Y. <br /> �a'� o <br /> Conditional . . . . . . cn N <br /> C <br /> 2. Classification Land Use . . . . . . a K <br /> Zoning Dist. . . . . . . <' 0 <br /> 6. Use (describe exact) , -fam. I <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 rI--� � <br /> existing structures, well, sewage sys- LQ 0 <br /> ' 1 tems, roads, etc., should be sketched �J <br /> 1,4N in Fig. A. Include road setback, side <br /> and back yard dimension and location U' a <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 W <br /> Alt <br /> Subdivision.....$25.00 + $2.00 per lot. I <br /> Land Use................................. $10.00 <br /> Building................................... 10.00 <br /> Sanitary .................................. 20.00 <br /> W 9 Well ........................................ 10.00 <br /> tilt Septic Tank ............................ 10.00 <br /> Privy ....................................... 5.00 <br /> -........:- ---...----..................... _...i/1.�...� ............ .... ..... - ............... <br /> Signature of Owner or Agent ate 'Hing istrator <br /> Inspection Date . ' ....1./G:."....G'..`�................. Inspector . ( .. .. 6 - ..:2... <br /> Remarks ��J. ;L.i7 .. C'71��,;e ....../ ./. ........................................... <br /> .................... '. ...: 17« "'.... .. ................................................................ <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 />