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Burnett County Office of Zoning Administrator CH I CCT f'1 <br /> an 1 O -1 Z <br /> APPLICATION FOR SANITARY — LAND USE =`BUILDING PERMIT <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a '• o op <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, c .!!� :O <br /> Sanitation Codeta and with all other applicable County Ordinances and the laws and regu v •'1 <br /> lations of the State of Wisconsin. <br /> o <br /> . . 4 . it. Z.i5. . . .MI � �IN <br /> qO <br /> Owner or Agent (please print) Contractor or Surveyor -t- <br /> 7 xsT H /so <br /> Address, �A.dtlress � "C <br /> iC <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Phqne. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . — v i <br /> Phone ;V <br /> Plumber 1Nelh Driller <br /> 0 <br /> Address Address <br /> Phone . . . . . . . . . . . . . . . . . . . . . . . . an � r '-Z-- <br /> DESCRIPTION 4, Building Details T Sanitary Facilities <br /> Type of nstruction No. Bathrooms "J— W Z Z o <br /> ,Go <br /> 1. Work /� �° V^' � Dishwasher ° ° A <br /> New Building . . .L-i Size ft. x .�7. `�.-. ft. Garbage Grinder <br /> Addition / Height . . . . . Stories . . . . . . Autom. Laundry <br /> yy <br /> Sanitary V. . Area . . . . . . . . . . . . . . . . . . . No. Bedrooms . . <br /> Alterations Waste Disposal System . . . . . �� .C � ° <br /> Moving . . . . . . 5. Permits Required Septic Tank Size Gals. IA'O.e". . <br /> Wrecking . . . . . . Subdivision . . . . . . Absorption Field Site <br /> Mobile Home . . . . . . Sanitary . Arm� Soil Type . . . . . . . . . . . . . . . . . m ns ~ '� <br /> Privy Building . Slope . . .. . . . . . . . . . . . m "� <br /> Well . .�. Well . . � Pere. Rate . . . . . . . . . . . . . . . . . <br /> Subdivision . . . . . . Other (Specify) Dry Well <br /> Conditional Seepage Trench 'U` ''e c w <br /> 2. Classification pp,y Land Privy . . ;0 Tc, 'n <br /> Zoning Dist. 41.h .Q. Seepage Bed /per•(:-� .0 a o <br /> 6. Use (describe exactly, -fam. <br /> 3. Lot Size home,motel,etc) FOR COMMERCIAL USE i } <br /> .�. �. �. . <br /> it.x 'd �.t . ft. Plans Submitted . . . . . . c !� <br /> . . . . . . . . . . . . . . . . . . sq.ft. Plans Approved <br /> ------------------------------------------------------------_ <br /> FigA. Location of <br /> y proposed structures and <br /> I}� existing structures, well, sewage sys -0 <br /> y`� C teras, roads, etc., should be sketched <br /> I in Fig. A. Include road setback, side E� °1b z <br /> _ and back yard dimension and location <br /> , ' Sr and setback from all bodies of water. <br /> If property is located at a highway in <br /> r tersection, show the intersecting high <br /> �SO--.��/�r �•o° ways and the setbacks required along n :� <br /> f E7 �r them and at the intersection. <br /> PERMIT FEES • <br /> l01� y <br /> s�bdivisign . . . $15.00 Z`. <br /> �� � � "y - wT•� Land Use . . . . . . . . . . . 1.00 <br /> Building . . . . . . . . . . . 5.00 <br /> Sanitary 10.00 <br /> Well . . . . . 5 _ .�. <br /> Septic Tank . . . Q�pJ � <br /> 'Combination Building, Sanitary <br /> R x// and WellIL <br /> { Sign Gre of Owner or Agent Date Zon' Administrator <br /> Ins ection Date .,, .../... ,may <br /> p /. .........��.T Z. Inspector .�fff:.(LFZ2C-<z..Lf cl�/XQ„6:cy..._.., ......_.............._. <br /> Remarks 11...!1 .��..�./.-CZE`. c......_.9- . - �1.. .r.........................._......_......._..............__.._.._. <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'• SVSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />