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Burnett County — Office of Zoning Administrator `Cn/ _V 0 -4 z <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT °. 3 F <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 m <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- v <br /> llaatiiio'ns of thje//tate of Wisconsin. ///��)/`,p . A/ a i iZ <br /> Owner or Agent (please print) Con actor 6r Surveyor n c :lam <br /> Address ddress <br /> Phone Phone _ :� ✓1 <br /> .-rl"o, <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . :A <br /> Plumber Well Driller <br /> . . . . . . . . . . . . . . . Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 <br /> n o 0� <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Phone Phone m r- <br /> 0 <br /> o <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: y <br /> Typepfonstruction No. Bathrooms r• • • o z 0 <br /> 1. Work t` . . . . . . . . . . . . . . . . No. Bedrooms . . . ° m ' <br /> New Building . . . Size . l.z. ft. x . ..2.y. ft. Septic Tank Size Gals. /600 \ <br /> Addition . . . Height .�. . Stories . /. . . . """VVVj 'J <br /> Sanitary x. . Area . . . . . . . . . . . . . . . . . . . 7a.Absorption Field S'Je:� <br /> Soil Type7- oFilling . . . . . . Ri� � <br /> .. <br /> Moving5. Permits Required Slope . . . <br /> �. .SIA/9*. . . . 1 <br /> Grading Subdivision Perc. Rate . . . . . . . . . . . . . . . . . r <br /> Mobile Home . . . . . . Sanitary Dry Well m m <br /> Privy . . . . . . Building Seepage Trench . . . . . `D fD <br /> Well . . . . . . Well Privy . . . . . . <br /> Subdivision • • , , , Seepage Bed o <br /> Other (Specify) ` c <br /> Conditional <br /> o rn (n <br /> 2. Classification Land Use . . . . . . a <br /> Zoning Dist. . . . . . . o <br /> 6. Use (describe exactly�1 - fam. <br /> 3. Lot Size home)motel,etc.) FOR COMMERCIAL USE <br /> 0 <br /> . . . . . . . . . ft. x . . . . . . . . ft. Plans Submitted . . . . . . <br /> . . . . . . . . . . . . . . . . . . sq. ft. Plans Approved . . . . . . <br /> ------------------------------ ------------------- <br /> Fig. A. Location of proposed structures and � <br /> 01 existing structures, well, sewage sys- <br /> tems, roads, etc., should be sketched <br /> in Fig. A. Include road setback, side ' s <br /> C� and back <br /> y�`y Seo a yard dimension and location <br /> + and setback from all bodies of water. <br /> Spl ��� If property is located at a highway inIvy <br /> / tersection, show the intersecting high- <br /> )kl, ways and the setbacks required along i (-- <br /> theand <br /> nd at the intersection. <br /> /00/ PERMIT FEES <br /> �o <br /> d. o,/ Subdivision..... $25.00 + $2.00 per lot. D <br /> Land Use................................. $10.00 N� <br /> Building................................... Q ':7) J <br /> Sanitary ................................ -�. . <br /> �. 5</sf�,/ Well ........................................ 10.00 <br /> Septic Tank 616�005 611 <br /> Taa* Privy ....................................... 5.00 <br /> . ...... ... .... . ................................ i <br /> .. ........5—J9�7......... ... .Y. . <br /> S' ature o ner or Agent Date 7 oni g/A ryes ministrator <br /> 7 <br /> Inspection Date . ...I......./.../......................... 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 />