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Burnett County Office of Zoning Administrator Z <br /> CD CD 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ° 3 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 y <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, X, M r <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- _0 0. 'l , <br /> lations of the State of Wisconsin. `-° O <br /> i,�Q, <br /> A 1m e,.Y.. . . . . . . . . . <br /> _. <br /> D , -. . . . . . . . . . . . . . . . <br /> - � <br /> ID <br /> Owner or <br /> Agent (please print)` Q I Contractor. or. Surveyor N <br /> `D <br /> Address Address <br /> a <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . �' <br /> Phone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Phone . . . . <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Plumber Well Driller <br /> 0 <br /> Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o <br /> 0 < <br /> o <br /> CD <br /> Phone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CDPhone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> 0 <br /> N <br /> n <br /> o <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: ° _0 <br /> / Tie of Constru qn , No. Bathrooms • . • • • • o Z �° <br /> 1. Work / t�O tY�Z, 4 . .I0q� . No. Bedrooms �-.. ° <br /> VVV// <br /> CD <br /> New Building Size . .? ft. x . �-4. ft. Septic Tank Size Gals. <br /> Addition Height .�. . .F�Stor es . . . . . . . . . . . <br /> t 7a.Absor tion Field Site: <br /> Sanitary . . . . . . Area .J.7.�.:�t�. . . . . . . . p m <br /> Filling . . . . . . �ivXZ� ��o Soil Type . . . . . . . . . . . . . . . . . . o <br /> Slope <br /> � <br /> Moving 5. Permits Required p <br /> Grading . . . . . . Subdivision Perc. Rate . . . . . . . . . . . . . . . . . <br /> Mobile Home / Sanitary Dry Well CD CD <br /> Privy F! Building Seepage Trench fD `D <br /> Well Well ,/ Privy fA <br /> Subdivision Other (Specify) . . . . . . Seepage Bed . . . . . . o <br /> Conditional . . . . . . N <br /> CD <br /> 2. Classification (� Land Use <br /> Zoning Dist. J.,. . a <br /> 0 <br /> 6. Use (describe exactly, 1 -fam. y' <br /> -�j 0 <br /> 3. LQ_, ji a home, motel,etc.) FOR COMMERCIAL USE I '� <br /> �. ft x r6tqo . ft. Plans Submitted . . . . . . <br /> .4�. . f74r�sq. ft. '��� Plans Approved r <br /> ------------------------------------------------- proposed <br /> p------------ <br /> Fig. A. Location of ro osed structures and r <br /> r�existing structures, well, sewage sys- <br /> tems, roads, etc., should be sketched = <br /> 'Z $3 in Fig. A. Include road setback, side <br /> and back yard dimension and location <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 <br /> �g0 Subdivision..... $25.00 + $2.00 per lot. CD <br /> Land Use................................. $1 <br /> 0.00 <br /> Building................................... <br /> Sanitary .................................. 20.00 <br /> 11 Septic Tank ............................ 10.00 <br /> Privy ....................................... <i2D <br /> 30 <br /> Gl:....o .....�.... a.a.-?q_ _ ..................... <br /> : ............. 9 Signature of Owner or Agent Date g 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 />