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Burnett County Office of Zoning Administrator o --i Z <br /> �LICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 o <br /> J <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, - V <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- v a ^ <br /> lations of the State of Wisconsin. `-° .07 0 <br /> 3 <br /> T.,,i�l. . . . . . P h s C ✓\ S o <br /> Owner or Agent (please print) Contractor or Surveyor <br /> r�. <br /> a. G. .� . . . . v. . . . s r. . . . . . . a - <br /> Address <br /> Address <br /> tv�r y . . � <br /> Pho e Phone <br /> `. . . <br /> Plumber. . . . . . . . . . . . . . . . . . . . .Well Driller. . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Sr <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adcdressress — <br /> O : s <br /> Address 0 0 <br /> ° G <br /> r�"`�\ 0 <br /> Phone Phone . . . . . . . . . . . . . . . . . . . . . . . . . . . : vm y r <br /> ° o <br /> � o <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: -O <br /> Type o onstruction No. Bathrooms o Z .°° <br /> 1. Work . . . . . j-.��Q. !' ;�. No. Bedrooms a` ° :,r„ <br /> New Building . . . ?� Size ft. x . �. - ft. Septic Tank Size Gals. . ., . . . .� v1 <br /> Addition . . . . . . Height . . . . . Stories . . . . . . <br /> \ .m <br /> Sanitary . . . Area . . . . . . . . . . . . . . . . . . . 7a.Absor Ption Field Site: <br /> Filling . . . . . . Soil Type . . . . . . . . . . . . . . . . . . o <br /> Moving q Slope N <br /> 5. Permits Required <br /> Grading . . . . . . Subdivision Perc. Rate . . . . . . . . . . . . . . . . . <br /> Mobile Home . . . . . . Sanitary- . .E�� Dry Well . . . . . . i!� i <br /> Privy . . . . . . Buildiny Seepage Trench `° nrjt <br /> Well . . . . . . Well C/. Privy <br /> Subdivision . . . . . . Other (Specify) , , , , . , Seepage Bed <br /> Conditional <br /> 2. Classification Land Use <br /> Zoning Dist. <br /> 6. Use (describe exact 1 - fam y <br /> 3. Lot Size home, motel, etc.) FOR COMMERCIAL USE ° <br /> e . . . ft. x . . . ft. Plans Submitted . . . . . . <br /> 1� <br /> sq. ft. Plans Approved . . . . . . <br /> ------- ----- 6r*(I�------------- --------------- - : -i-t NQ <br /> � J11 �� Fig. A. Location of proposed structures and i <br /> existing structures, well, sewage sys- o <br /> t tems, roads, etc., should be sketched <br /> T <br /> W in Fig. A. Include road setback, side � s <br /> and back yard dimension and location <br /> and setback from all bodies of water. ! <br /> l (,� If property is located at a highway in- '\i (�- <br /> [t tersection, show the intersecting high- C� <br /> ways and the setbacks required along :y T <br /> them and at the intersection. <br /> PERMIT FEES n <br /> v� <br /> �0o V .still Subdivision..... $25.00 + $2.00 per lot. <br /> Land Use................................. $10.00 <br /> Building 0. <br /> c v f Wel .Sanitary................................... 2� ?�— <br /> Well .. <br /> Septic Tank .. 10.00 T <br /> Privy ....................................... 5.00 <br /> . <br /> � L <br /> Signature of Owner or Agent Date} Zoniny Administrator <br /> Inspection Date Inspector - <br /> ............................... <br /> . .......... <br /> Remarks ...... k':t'....�G� f,��,,,�12,E- .G?' L/.,i �crs�->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 />