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Burnett County Office of Zoning Administrator f N oz <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ° <br /> r <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application fora 0 = o J� <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, \►J <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- -0 ° <br /> lationsrrof the State of Wisc sin. 3 a O <br /> JDA . . i�/ Y. . . . <br /> Owner or Agent lease print Contractor or Surveyor N `� <br /> . . . . .h4.b 5f�K_ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0. <br /> Address Address <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v <br /> Phone Phone <br /> v <br /> . <br /> Plum. b.er W. .ell. .Driller . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> w.E. Sfr. . . . . . . . . . . <br /> Address Address ` 1 0 0 ;(\ <br /> . . .ne. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .P.hon. .e. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Phor <br /> M H <br /> o <br /> o <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities / <br /> Type of Construction No. Bathrooms . . . z z o <br /> 1. Work . . . . . . . . . . . . . . . . . . . . . . . . Dishwasher . . ./76 ° ° �o <br /> New Building . . . . . . Size . . . . . ft. x . . . . . . ft. Garbage Grinder f?v. :✓`' <br /> Addition . . . . . . Height . . . . . Stories . . . . . . Autom. Laundry <br /> Sanitary Area . . . . . . . . . . . . . . . . . . . No. Bedrooms <br /> Alterations . . . . . . Waste Disposal System <br /> Moving 5. Permits Required Septic Tank Size Gals. 7 r L <br /> Wrecking . . . . . . Subdivision . Absorption Field Site f ; <br /> Mobile Home . . . . . . Sanitary Y. . . Soil Type l7hz! <br /> . . . . . . . <br /> Privy Building Slope . . Q. . . . . <br /> Well . . . . . . Well . . . . . . Perc. Rate . . . . .off. . . . <br /> Subdivision . . . . . . Other (Specify) . . . . . . Dry Well o <br /> Conditional . . . . . . Seepage Trench . . . . . . 11 <br /> 2. Classification Land . . . . . . Privy <br /> Zoning Dist. Seepage Bed ! O. a <br /> – 0 <br /> 6. Use (describe exactly, 1 -fam. H' <br /> 3. Lot Size home, motel, etc.) FOR COMMERCIAL USE ° <br /> . . . . . . . . . ft. x . . . . . . . . ft. Plans Submitted <br /> . . . . . . . . . . . . . . . . . . sq. ft. Plans Approved <br /> Fig. A. Location of proposed osed structures and <br /> Jvh � p p 0 <br /> � existing structures, well, sewage sys- i ; 0 <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 /> r I TG and setback from all bodies of water. <br /> If property is located at a highway in- �� 0 <br /> At tersection, show the intersecting high- <br /> ways and the setbacks required along <br /> Ver <br /> them and at the intersection. <br /> �te 1 I PERMIT FEES <br /> 'TI 1pl <br /> Subdivision . . . . . . . . . $15.00 <br /> 750 Land Use . . . . . . . . . . . 1.00 <br /> Building . . . . . . . . . . . 5.00 <br /> Sanitary . . . . . . . . . . 10_00 <br /> Well . . . . . . . . . . . —5.00 <br /> Septic Tank 1.00' <br /> Combination Building, Sanitary <br /> and Well . . . . . . . . 15.00 <br /> ............................ - ..-.�..z . ...% ` . <br /> Sig lure of Owner or Agent <br /> 77 Date ng A��"' istrator <br /> Inspection Date .... ... . .. ..........4..,1../... .... Inspector 7. ... . .. . .... ............................ <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 />