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�?jBurneIL County Office of Zoning Administrator n a 0 -f z <br /> o , o <br /> APPLICATION FOR SANITARY — LANDUSE BUILDING PERMIT <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a o :v <br /> Permit for the work described and located as shown herein. The undersigned agrees that all YI :-4Z <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. A c <br /> lations of the State of Wisconsin. 3 c, p <br /> wR na.6��. . ,J. . = a <br /> O na, o Agent (Please print) . Contractor or Surveyor <br /> I c3sre— LU(S'C t <br /> 1 F . . . . . . . . . . . I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . _ . . : . . . . . . . . . . . . <br /> C <br /> Address Address c <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Ph . . - <br /> one Phone \$ <br /> NlecS KoeePe _ . . . . . . . . . . . . . . _ . . . . h <br /> Plumber Well Driller !G <br /> .�•� ��j S��r-- i l.l)f S L Q o ('� <br /> Address � � � � � � � � � � � � � � � � � � � � � � � Atldress <br /> . . . <br /> Phone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i+r a � <br /> Phone <br /> 0 <br /> o <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: , <br /> Type of Construction No. Bathrooms Z ° i <br /> 1. Work I . .. . . . . . . . . . . . . . . . . . . . . No. Bedrooms ° <br /> New Building . . . . . . Size . . . . . ft- x . . . . . . ft. Septic Tank Size Gals. <br /> CSaniAddition . . . . . . Height . . . . . Stories . . . . .. U <br /> : 7a.Absorp[ion.Field <br /> d Site:r v1 ii <br /> tary Area . . .. . . . . . .. . . . . .. :Soil TypeFilling .r <br /> Moving . . . .. . 5. Permits Required Slope . . � 7U <br /> Grading . . . . . . Subdivision Perc. Rate z tJ � <br /> . r ? . . �. <br /> Mobile Home Sanitary ,a",', Dry Well <br /> Privy . . . . . . Building Seepage Trench <br /> Well Well Privy <br /> W LU <br /> Subdivision . . . . . . Other (Specify) . . . . Seepage Bed <br /> Conditional . . \0 u u <br /> 2. Classif i<ationnpp Land Use L,l <br /> Zoning Dist. 1R!1.", <br /> Tl 6. Use (describe exact) , 1 -fa yn <br /> 0 <br /> 3. Lot Size home, motel,etc.). .FOR COMMERCIAL USE <br /> W <br /> .}�. . . R. x t ! . . ft. Plans Submitted . . . . . . 0 i o <br /> . . . . . . . . . . . . . . . . . . sq. ft. Plans Approved . . . . . . om [ [N <br /> ____________________________________9_____-_______y_Y -i <br /> Fig. A. Location of proposed structures and <br /> existing structures, well, sewage s s- 'd ' o <br /> tems, roads, etc., should be sketched <br /> in Fig. A. Include road setback, side , <br /> and back yard dimension and location :� a <br /> and setback from all bodies of water. <br /> If property is located at a highway in <br /> lersection, show the intersecting high a t: G, <br /> ways and the setbacks required along <br /> them and at the intersection. <br /> xs.l <br /> PERMIT FEES <br /> °G <br /> Subdivision..... 525.00 + 52.00 per lot. ' sem. <br /> Land Use................................. SIDED <br /> Building................................... 10.00 <br /> Samtar...—�............... ............... 35.00 <br /> Well ............................... 10.00 <br /> Privy ..._.................................... 5.00' <br /> b 35.aa <br /> u <br /> am..... <br /> Signature of Owner ore i'�� Date - Zoningm Adnest ator <br /> 7` �� art.. a.e................ <br /> . <br />. Inspection Date!:....:.......�......._.._ ................ Inspector _ ._. .. :L{-�'."'%.Cr <br /> / ]may ..............1......... <br /> \ <br /> Remarks Z(- 1��!�CF!.., , —/. ........ i <br /> ..............._......_..... <br /> .......................................... <br /> ............................................................................................................. <br /> NOTE:"A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities <br /> l <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 /> ino unlit a permit has been Issued. A permit may be revoked if misrepresentation of any of the information conveyed here=l <br /> with is found to exist. Changes in plans or specifications shall not be made without approval of the Zoning Admimslrai,n. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />