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4 Burnett County Office of Zoning Administrator 9 0 z <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT o 3~ f <br /> TO -THE ZONING ADMINISTRATOR: The undersigned hereby makes application-for a ° <br /> Permit for the work described and located as shown herein. The undersigned.- <br /> agrees that all <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 tern- v o- (p1 <br /> lations of the State of Wisconsin. <br /> 3 r V O <br /> o C: . . _ <br /> O (n�et orr }�ge/hi (Please print) Contractor or Surveyor <br /> Address Address a <br /> c 7 <br /> Phone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Phone . . . . . . . . . . . . . . . . . . . . . . . . . . . !f�,' :� <br /> p -/ W <br /> t� . . .`.P. n. . . . . . . . . . . . . . . . . . . . . . . . _ . . : . . . _ . . . . . .'_ . . . . . . . . . . :� € <br /> Plumber Well Driller <br /> :v <br /> �.M o <br /> Address . . . . . . . . . . pp . . . . . . . . . . . . . . . . . . .Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .' '�I A m m <br /> p � < <br /> Phone 1 Phone r :1 <br /> 0 <br /> DESCRIPTION 4. Building Details ! 7. Sanitary Facilities ? v <br /> Type yf Comt uction No. Bathrooms . _ . �. z <br /> 1. Work . . . . r!'A( ,�Y S?XlS �fhf Dishwasher <br /> New Building . . . . . . Size . . . . . ft. x . . . . .. ft. O Garbage Grinder <br /> Addition Height . . . Stories . . . . . . Autom. Laundry <br /> . .,. .- / . . . . . . <br /> Sanitary . .�/ Area . . . . . . . . :. . . . . . . roena <br /> . . . <br /> Waste D . . '� <br /> Alterations . . . . . . Waste Disposal System . >.S.J ° <br /> Moving . . . . . . 5. Permits Required Septic Tank Size Get.. <br /> Wrecking . .. . . . Subdivision Absorption Field Site <br /> Mobile Home . . . . Sanitary . . . Soil Type . . . . . . . . . . . . . . . . . . a A <br /> Privy . . . Building . . . . . . Slope . . . . . . . . . . 'r <br /> Well . . . . . . Pere. Rate . . .� .*.- <br /> Well . . . . . . mw <br /> Y,f <br /> o° <br /> Subdivision . . . . .. Other (Specify) . . . . . . Dry Well <br /> Conditional . . . . . . Seepage Trench <br /> 2. Classification Land . a <br /> Privy c ° <br /> Zoning Dist. . . . . . . Seepage Bed f.. . : n o <br /> fi. Use (describe exaely, 1 -fam i <br /> 3. Lot Sizg ,x home, motel,etc.) FOR COMMERCIAL USE ° <br /> ° i • <br /> �.0.�. . ft. xJr :f.Y ft. Plans Submitted. . . . . . . . . . . . . . . . . . sq. ft. Plans Approved � -� � � � _ <br /> Fig.A. Location of 'I <br /> proposed structures andy <br /> / existing structures, well, sewage sys- e F <br /> tems, roads, etc„ should be sketch eJi <br /> in Fig. A. Include road setback, side '0 <br /> �+ and back yard dimension and location - a <br /> 31 1 and setback from all bodies of water. <br /> SN Q 1` If property is located at a highway in. <br /> 9�1 trisection, show the intersecting high- y��\ <br /> _ ways and the setbacks required along " Z <br /> ;them'znd2t,the intersection. '.. <br /> L PERMIT FEESLU 9 <br /> Subdivision S15.00 <br /> Land Use . . . . . . . 1.00 (Q�j <br /> Building . . . . . . . . . 55-000, <br /> Sanitary . . . . . . . . . . <br /> Well . . . . . . . . 5.00 <br /> " �aX <br /> Septic Tank <br /> Combination Building, Sanitary <br /> and Well . . . . . . . 15.00 O <br /> Signature ufx0 Date ning � min ist rotor <br /> Inspection Da to ..... .. .../... .. ............ inspector ....1/..).... .' .SZK-Ll.eaL.............................. <br /> Remarks ............................. ...... ............/ . ..�........................................... .............. <br /> ......I..._.._.. .......---. �.......�........_.... `: -...77=1.................................................. <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 /> � <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 ti5s been issued. A permit may be revoked if misrepresentation of any of the information conveyed here .I <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 />