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Burne`-t County Office of Zoning Administrator o -i Z <br /> a O O <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT °_ 3 <br /> TO THE ZONING ADMINISTRATOR : The undersigned hereby makes application for a _ o <br /> Permit for the work described and located as shown herein. The undersigned agrees that all <br /> C <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- <br /> latiDns of the State of Ifisconsin. a O <br /> fi.4.(7 . <br /> or Agent (please print) Contractor or Surveyor <br /> . . . . . . . . . . . . . <br /> Adss ! Address aS <br /> S.T. . P.rt. .C. . . . . . . . . . . . . . . . . . . . . . . <br /> Phone Phone <br /> ,]�1n I J . . . . . f . . . . . . . . . . . . . . . . . . . . . . <br /> Plu-rriberr, / � Well Driller <br /> Address - . . . . . ,. . . . . . . . . . .Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \1 r <br /> �� w o <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Phone Phone � <br /> n o» <br /> DESCRIPTION 4. Building Details A��7. Sanitary Facilities: O <br /> Type of Constrdc No. Bathrooms . . . . . . <br /> o Z .°° <br /> 1. Work No. Bedrooms . • ° `D <br /> New Building .!/ Siz 9Clt�. Zft. x � ft. Septic Tank Size Gals. <br /> Addition . . . . . . He i ht Stories .l <br /> Sanitary . . % Area . . 7a.Absorption Field Site: <br /> Filling . . . . . . Soil Type . . . . . . . . . . . . . . . . . . ' V o Moving . . . . . . 5. Permits Required Slope . . . . . . . . . . . . . . . . . " <br /> Grading . . . . . . Subdivision . <br /> Pere. Rate . . . . . . . . . . . . . . . . . o <br /> Mobile Home . . . . . . Sanitary 4-/� Dry Well . . . . . . <br /> Privy / Building � Seepage Trench . . . . . . C `° `° —} •-o :� <br /> Well . . .V. Well . . � Privy <br /> Subdivision (Specify) Seepage Bed <br /> . . . . . Other . . . . . . <br /> Conditional . . . . . . <br /> C <br /> . . . . . . <br /> 2. Classification Land Use 0 <br /> � '.6 a <br /> Zoning Dist. ° <br /> L <br /> 6. Use (describe exact , 1 - fam <br /> 3. Lt Size '? home, motel, etc.) FOR COMMERCIAL USE <br /> ft. x <br /> .�Q. J.O.". ft. Plans Submitted <br /> . . . <br /> . . . . . . . . . . . . . . . . . . sq. ft. Plans Approved . . . . . . <br /> Location of proposed structures and <br /> r v Av existing structures, well, sewage sys- �. 0 <br /> terns, roads, etc., should be sketched :n <br /> / a""SII - � in Fig. A. Include road setback, side <br /> �� „�.II ��� E�►� and back yard dimension and location `s <br /> and setback from all bodies of water. _i - <br /> If property is located at a highway in- :p <br /> :`•� <br /> tersection, show the intersecting high- ol, <br /> ways and the setbacks required along ? %' <br /> M. them and at the intersection. <br /> PERMIT FEES <br /> Subdivision..... $25.00 + $2.00 per lot. <br /> �� Land Use................................. $10.00 <br /> S I ,u . l Building................................... 10.00 <br /> _..- <br /> -= Sanitary .................................. 20.00 <br /> /oo ' Well ........................................ 10.00 <br /> 4 <br /> Septic Tank 10.00 \ "~ <br /> Privy ....................................... 5.00 •., <br /> y-c` 1�o�•, �, k Ire - <br /> ��...'.... ...... ...........^' ` ......................... ......i1. 6. 7..f.. l� . .. ... .. . ...................... <br /> Signatu a of Owner or Agent Dat /r o ing Administrator <br /> l <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 />