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Burnett County Office of Zoning Administrator`s Cn _V �o Z <br /> CD C 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ° <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a = 0 <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 <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- v <br /> lations of the State of Wisconsin. a v <br /> 7L-1. . . .C>'k/Ff. . . . . . . . . . . . . . . ale, -T/1.A.F .oa-� . . . . . . . <br /> Owner or Agent (please print) ontr or or SurveyorCD <br /> N � `�° <br /> 0_ <br /> �/7 ./3 v. .11 <br /> . . . . . . . . . . . . . . . ; <br /> Address . . . . . . . . . . . . . . . .dress 1 Address y a �: <br /> Phone Phone <br /> Plumber Well Driller <br /> 0 <br /> Address Address m G) <br /> 0 <br /> 0 ; <br /> Phone Phone m y r- <br /> 0 ,.., 0 <br /> m o �' <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: ° <br /> Type of Construction No. Bathrooms o Z <br /> 1. Work die' <br /> .�}f�.f1 .�. . . . . No. Bedrooms °New Building . . .f�40 ft. x . .3 y ft. Septic Tank Size Gals. . . . <br /> Addition Height . . . . . Stories . . . . . . <br /> 7a.Absor tion Field Site: <br /> Sanitary . . . . . . Area . . . . . . . . . . . . . . . . . . . p r- <br /> Filling . . . . . . Soil Type . . . . . . . . . . . . . . . . . . 0 <br /> Moving q Slope. . . . . . 5. Permits Required Re • • • • . • • • • • • • • • • • • • • • <br /> Grading . . . . . . Subdivision • . • • • . Perc. Rate . . . . . . . . . . . . . . . . . <br /> Mobile Home Sanitary : ; Dry Well m C <br /> Privy . . . . . . Building Seepage Trench . . . . . . `D `D <br /> Well . . . . . . Well Privy . . . . . . tr fA <br /> o <br /> Subdivision Other (Specify) . . . . . . Seepage Bed . . . . . . o <br /> Conditional . . . . . . o c m <br /> 2. Classification Land Use . . . . . . 0 h <br /> Zoning Dist. �. . ° o <br /> 6. Use (describe exactly, 1 - fam. y' <br /> 0 <br /> 3. Lot Size om otel,etc.) FOR COMMERCIAL USE 0 <br /> / -ft. x . . . . . . . . ft. Plans Submitted . . . . . . <br /> . . . . . . . . . . . . . . . . . . sq. ft. Plans Approved . . . . . . - <br /> ------------ <br /> Fig• Location of proposed structures and <br /> existing structures, well, sewage sys- :; o <br /> tems, roads, etc., should be sketched <br /> 0 <br /> --. in Fig. A. Include road setback, side T <br /> G. r 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 /> G them and at the intersection. <br /> Vet_ PERMIT FEES <br /> �L Subdivision..... $25.00 + $2.00 per lot. fD <br /> Land Use................................. $10.00 <br /> .1 u i I din-a—................................. 10.00 <br /> Sanitary .................................. 20.00 <br /> Well ........................................ 10.00 <br /> r\ / Septic Tank ............................ 10.00 <br /> Privy ....................................... 5.00 <br /> .74././/. . ,�.. ... .............. 1.. -. .. . .. .................. <br /> Signature bf Owner or Agent Date Zoning Administrator <br /> InspectionDate ................................................ Inspector ................................................................................................ <br /> Remarks ............................................................................................................................................................ <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 />