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Cnl C61 tt � <br /> Burnett County Office of Zoning Administrator <br /> m m y 0 O <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 9 3 <br /> (1� <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application fora = o <br /> Permit for the work described and located as shown herein. The undersigned agrees that all m W <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, F m ' <br /> Sanitation Code and with all other applicable County Ordinances and the laws and regu- -0 <br /> latioate of Wisconsin. 3 o <br /> a � <br /> f the S . . : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> �.< K Y <br /> Own r or Agent (lease. .print). . . . . Contractor or Surveyor <br /> J7.d`►. . . .�. �j�oE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _ <br /> a <br /> Address Address <br /> a <br /> 7/ <br /> . . . . . . . . . . . . . . . . . . <br /> Phone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Phone <br /> W <br /> Plumber We Driller ' <br /> Address . . . . . . . . . . . . . . . . . . . . .Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> 0 0 <br /> f0 T .�/o Y Y rv ' o < <br /> Phone - Phone <br /> n 0 <br /> L o <br /> DESCRIPION 4. Building Details 7. Sanitary Facilities: -L .» 71 P� <br /> Type of Construction No. Bathrooms . . o z 0 <br /> 1. WorkZ 91 No. Bedrooms <br /> New Building . . .X . Size Z ft. x .5. . ft. Septic Tank Size Gals. <br /> Addition . . . . . . Height . . So dies . . . . . . . . . . . N f <br /> Sanitary7a.Soil T tion Field Site: r <br /> A. Area . . ./. 1?9. . . . . . . . . . . P 1. <br /> Filling j . . . . . . . . . . . . Soil TYPe . . . .! ..+� . . . o <br /> Moving . . . . . . 5. Permits Required Slope E <br /> . .7 °79. . . . . 4.� . . : . <br /> Grading j . . . . . . Subdivision Perc. Rate .3. :-..'�—' � <br /> Mobile Home . . . . . . Sanitary , , K, , Dry Well . . . . . . f;. ,M <br /> Privy . . . . . . Building , ,X_ . . Seepage Trench . . . . . . I m m <br /> Well . . . . Well . .K . . Privy . . . . . . <br /> Subdivision . . . . . . Other (Specify) , , . , , . Seepage Bed . . . . . . <br /> Conditional <br /> 2. Classification Land Use . . . . . . yJ. :a cr <br /> :�n 0 <br /> ZoningDist. it � � 0o <br /> 6. Use (describe exactly, 1 -fam. J N <br /> 3. Lot Size home, motel,etc.) FOR COMMERCIAL USE — 0 <br /> . 1.0.v. . . ft.UV 1.0 v. . ft. / F 4+4 r -�/ Plans Submitted . . . . . . l1 V.f <br /> . . . .4Z JF . . . . sq. ft. Plans Approved . . . . . . <br />--------------}----------------------------------------------- C----- <br /> Fig. A. Location of <br /> proposed structures and <br /> existing structures, well, sewage sys- o <br /> tems, roads, etc., should be sketched <br /> in Fig. A. Include road setback, side <br /> and back yard dimension and location <br /> and setback from all bodies of water. :V <br /> If property is located at a highway in- i <br /> . T <br /> 7i00 tersection, show the intersecting high- <br /> W ways and the setbacks required along <br /> them and at the intersection. <br /> _ <br /> y y PERMIT FEES <br /> W i1 Subdivision . . . . . . . . . $15.00 fO <br /> 0 <br /> -7(— <br /> (� Land Use . . . . . . . . . . . 1.00 js <br /> O 0 Sto/ Building . . . . . . . . . . . 5.007 <br /> L <br /> Sanitary . . . . . . . . . . . 10.00 A <br /> 'Y Well 5.00 <br /> Septic Tank . . . . . . . . V. 0 <br /> •� Combination Building, Sanit <br /> j and Well . . . . . .Privy . . . . . . . . . . <br /> te oyf <br /> gSignatrrn inistrato� <br /> Inspection Date .i.(((.///(p.'.!�.Q..`.. ................ Inspector ....... <br /> / a ... ... ..... ...........S6Z P_h�.. .. ........ <br /> ema ,�— <br /> ............ �ks <br /> k ' ��... ...... .. .. .��W+"!.c'.'. .....$...:'. ...a. ........... ......... <br /> ............. .� ? ....7�1 ,W..................................................................................................................................... <br /> NOTE: A prelimi ary 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 bfore 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 />