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k 7 t Urcv/y. .� ,— <br /> h Office of Zoning Administrator y q o y <br /> Burnett County <br /> =� APPLICATION FOR SANITARY — LAND_i — BUILDING PERMIT <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a <br /> l ^ \ <br /> Permit for the work described and located shown herein. The undersigned agrees that all <br /> work shall be done re accordance with the requirements of the County Zoning Ordinance, F <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu a �)� <br /> nations of the State of Wisconsin. J.IG 3 a `b � O <br /> Ct . . .S.S. GG . . . . . . _ <br /> wner or AgA.Pent (please print) Contractor or Surveyot <br /> if. � .(��Ss. . . S,T,. . de�' s. :,SY?o.�. . . . . . . . . . . _ . . . . . . . . -0 <br /> Address <br /> / Address <br /> =.h <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> PhPhone <br /> _ <br /> . . . <br /> Plumber hnmt ./. LF4J :4� �7. _ . . . . . v t <br /> Well Driller <br /> �i O C <br /> gess Address O <br /> 'n o <br /> J:lo vn <br /> . . . . . . . . . . . . . . . . . . . . . . . <br /> Phone Phone o <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: o v <br /> Type of Construm.n No. Bathrooms , o Z o <br /> z <br /> 1. Work . . . .. . . . . . . . . Na. Bedrooms <br /> New Building . . . . . . Size .. . . ft. x . . . . . . ft. Septic Tank Size Gals. <br /> Addition Height . . . . . Stories . . . . .. .. ./. .. <br /> i <br /> Sanitary Area 7a.A5sorption Field Site- <br /> . . . . . . . . . . . . . . . . . . . <br /> Soil Type 1Ni <br /> Filling . . . . . . . . SAN.C. .. . . . "\\ . <br /> Moving . . . . . . 5. Permits Required <br /> Slope . . . . :9 .G. - >,3 ,-1 a � I <br /> Grading . . . . . . Subdivision <br /> Pere. Rate . . . . . . . <br /> Mobile Home . . . . . . Sanitary , . ! Dry Well . . . . . . m \I <br /> Privy . . . . . . Building Seepage Trench <br /> Well . . . . . . Well . . . . .. Privy <br /> Subdivision Other (Specify) Seepage Bed " ' <br /> 2. Classification Land Use .. . . . . ti P. <br /> Zoning Dist. . . . . . . - ^�` - 0 <br /> 6. Use (describe exactly, 1 - fam. <br /> o <br /> 3. Lot Size f��X 1`i home,motel,etc.) FOR COMMERCIAL USE ' % o .S <br /> a �a ft. Plans Submitted . . . . . . �� Y� <br /> . . . sq. it. Plans Approved U ' <br />.__________________________________________________________________ l� . <br /> Fig A. Location of proposed structures and ix bu' <br /> t.1 <br /> existing structures, well, sewage sys i Io <br /> terns, roads, etc., should be sketched �nN <br /> in Fig. A. Include road setback, side i. O �I <br /> and back yard dimension and location 4)n' <br /> and setback from all bodies of water. ij <br /> ,•� 13', <br /> If Property is located at a highway in �tersection, show the intersecting highjU �ways and the setbacks required along <br /> them and at the intersection. <br /> PERMIT FEESaSubdivi5ion 515.00 � No/e ^ - �, Land Use . 1.00 \(r � _ Building .Sanitary110.00Well o.�Septic Tank1?00 Combination Building, Sanitary - C <br /> and Well . . . . . _ 15.00 "\ <br /> Privy . . . . . . . . . . . . 5.00 a f <br /> Signature of w7ynler or2A gent q Date � J/�//� onAdmmislrafo/r/// `\\ <br /> Inspection Date ..(�.i. ':.l.i._�...d. /(.. .7... Inspector .......Y...1.. \'I <br /> Remarks ............ ............. .. ....... <br /> ......................... .....�...k.._..... ........... - ................_........_..._............ ...... ... . ...._....... ... .. ..) <br /> .............. ......... _ .......... ..I <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facildi <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached' <br /> this application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any buil <br /> Ing a til a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed he <br /> with is found to exist. Changes in plans or specifications shall not be made without approval of the Zoning Administrat! <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. 1� <br />