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Burnett County Office of Zoning Administrator <br /> cn v p __l <br /> D D N o ° <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT <br /> TO THE ZONING ADMINISTRATOR: The undersigned Uereby makes application for a 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, mil <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- -0 <br /> latio of the State of W isc sin. <br /> C. . 4,7 <br /> . <br /> �� . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 <br /> O7?r/rAgent (plea pr t) Contractor or Surveyor +U <br /> a <br /> . . . . . . . . . . . . . . . . . . . . . . . C <br /> Address �✓� Address a <br /> . . . . . . . . . . . . . . . . . . . . . . V <br /> Phone Phone <br /> c <br /> Drille <br /> � . . <br /> eme Well r L� <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . :�xv <br /> Address Address m 0 <br /> o <br /> Phone Phone �t r- <br /> 0 <br /> ° <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: <br /> Type of Construction No. Bathrooms • • • •`• o Z °° <br /> 1. Work g Size. . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . Septic Tank <br /> Si IL ° <br /> New Building . . . . . . Size . . . . . ft. x . . . . . . ft. Septic Tank Size Gals. <br /> Addition Height . . . . . Stories . . . . . . . . . . . . <br /> Sanitary Area 7a.Absorption Field Site: m <br /> Filling . . . . . . Soil Type ° <br /> Moving . . . . . . 5. Permits Required Slope <br /> Grading . . . . . . Subdivision Perc. Rate . . . . . �. . �. . . . . . - <br /> Mobile Home . . . . . . Sanitary , ,(/, Dry Well . . . . . . <br /> -n �; � <br /> Privy . . . . . . Building Seepage Trench . . . . . . ° m <br /> ffl fsi <br /> Well Well Privy / <br /> Subdivision . . . . . . Other (Specify) Seepage Bed 42 X. o <br /> Conditional . . . . . . V) N <br /> C � <br /> 2. Classification Land Use . . . . . . a <br /> Zoning Dist. . . . . . . 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 /> . . . . . . Plans Approved . . . . . . <br /> ---- --------------------- <br /> Location of proposed structures and <br /> existing structures, well, sewage sys- 0 <br /> tems, roads, etc., should be sketched <br /> in Fig. A. Include road setback, side <br /> L and back yard dimension and location o <br /> 40/ and setback from all bodies of water. <br /> n n / If property is located at a highway in- <br /> tersection, show the intersecting high- <br /> ways and the setbacks required along <br /> Sf�FrOn them and at the intersection. <br /> /pqo a� PERMIT FEES d <br /> qq � D <br /> ���E° Subdivision . . . . . . . . . $15.00 m <br /> Land Use . . . . . . . . . . . 1.00 <br /> Building . . . . . . . . . . . v <br /> Irk t—� Sanitary . . . . . . . . . 10.00 - i <br /> Well .- <br /> Septic Tank . . . . . . . (Q00 ) \\\ <br /> Combination Building, Sanitary <br /> Jand Well . . . . . : . . 15.00 <br /> Jl Privy . 5.00 <br /> ...... ......................... . ........ ................... ... . ..�. ... .�.� ..... 1tL�L...g... . . . . ....... . . <br /> ignature 0 ner or Agent Date Zon Ad istrator <br /> Q � 8 �� <br /> Inspection Date .....0.... ............-....................... Inspector ......... .. ............... <br /> Remarks ... .`<.......l. ............'4rp..Y� '`.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 SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />