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Burnett County <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 /> work shall be done in accordance with the requirements of the County Zoning Ordinance, l \\ <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- -0 ° : <br /> lations of the State of Wisconsin. a <br /> 3 d <br /> r :N <br /> EL.I/nl . .�i .ES . . . . . . . . . . . . . . . . . . . . . . . . . . . . N <br /> Owner or Agent (please print) Contractor or Surveyor WCL <br /> ; <br /> iCA <br /> Address Address <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Phone Phone <br /> . . . . . . . . . . . WellDriller <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ul : <br /> Plumber t <br /> 7)6 <br /> I _ <br /> Address Address m G) <br /> Phone Phone N <br /> 0 <br /> n „ O <br /> O <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: <br /> Type of Construction No. Bathrooms . • 1• Z Z <br /> 1. Work . . . . . . . . . . . . . . . . . . . . . . . . No. Bedrooms . . . <br /> 0 o a <br /> New Building . . . . . . Size . . . . . ft. x . . . . . . ft. Septic Tank Size Gals. . .75�0 <br /> Addition . . . . . . Height . . . . . Stories . . . . . . . . . . . . <br /> Sanitary . . Area 7a.Absorption Field Site: <br /> FillingSoil Type . . . . .S.Yt. . Z>. . . . �? <br /> 0 <br /> Moving 5. Permits Required Slope . . . . . .fr. .4. . . . . . . <br /> Grading . . . . . . Subdivision Perc. Rate . . . . . . . . . . . . . . . <br /> Mobile Home . . . . . . Sanitary Dry Well - m <br /> Privy . . . . . . Building . . . . . . Seepage Trench . . . . . . D D <br /> Well . . . . . . Well . . . . . . Privy . . . . . . **K, fn <br /> Subdivision Other (Specify) Seepage Bed <br /> Conditional . . . . . . N <br /> 2. Classification Land Use . . . . . . l <br /> Zoning Dist. l a o <br /> 6. Use (describe exactly, 1 -fam. :, H <br /> 3, Lot Size home motel,etc.) FOR COMMERCIAL USE o <br /> ` t x . . . . ft. Plans Submitted . . . . . . :,tN <br /> sq. ft. Plans Approved . . . . . . <br /> __ <br /> Fig. A. Location of proposed structures and 3 <br /> existing structures, well, sewage sys- 0 <br /> tems, roads, etc., should be sketched :ly <br /> in Fig. A. Include road setback, side s <br /> and back yard dimension and location <br /> 12: and setback from all bodies of water. '-- <br /> '✓r If property is located at a highway in- <br /> tersection, show the intersecting high- 0 <br /> -7-C ways and the setbacks required along <br /> them and at the intersection. <br /> j/ PERMIT FEES �i <br /> ,� c <br /> 7/a 7 Subdivision . . . . . . . . . $15.00 <br /> Land Use . . . . . . . . . . . 1.00 <br /> pBuilding . . . • . . . . ' . <br /> I y�7 Sanitary . <br /> 10.00 <br /> —� Well 00 n <br /> Septic TankQ00 <br /> 7S Combination Building, Sanitary <br /> and Well . . . . . . 15.00 <br /> Privy . 5.00 <br /> LQ vN <br /> 44KE <br /> Signature of Ow e or Agent Date oni Admin..... .. .... ........................ ................................ ......... e4 istrator <br /> s <br /> Inspection Date .l . /....... Inspector ✓r6'� cC ''' � ..—`................................... <br /> p ............... .,.. ..../...�..c......... ...... I................ .. <br /> Remarks .....er.4...Cr�:.Z/.... �1 ........................ <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 />