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Burnett County Office of Zoning Administrator N o --I Z <br /> n m m 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT a 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a '" 0, ,C!` <br /> Permit for the work described and located as shown herein. The undersigned agrees that all m N <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- <br /> lations of the State of Wisconsin. `, a O <br /> 3 <br /> Jo N- . . . . . .T� .0/f .L-L. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . =' <br /> Owner or Agent (please print) Contractor or Surveyor <br /> / . . . . .ss. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . � <br /> Address. Addre '\ <br /> Phone . . . . . . . . . . . . . . .Phone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .,.�': .� <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Plumber Nlell Driller <br /> \ o <br /> Address Address ' <br /> n 0 <br /> o <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> i <br /> Phone Phone 0 H 0 <br /> o <br /> m a <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: <br /> Type of Construction No. Bathrooms • • • • • • o z 0 <br /> 1. Work . . . . . . . . . . . . . . . . . . . . . . . . No. Bedrooms . . . . . . <br /> New Building . . . . . . Size . ./,Z ft. x . . .1'� ft. Septic Tank Size Gals. . . . . . . <br /> Addition . . . . . . Height . .3. . .$tori . . . . . . 'gyp <br /> Sanitary . . . . . . Area . . . . . . . . . . . . . 7a.Absorption Field Site: <br /> Filling . . . . . . Soil Type . . . . . . . . . . . . . . . . . . o <br /> MovingSlope <br /> . . . . . . 5. Permits Required . . . . . . . . . . . . . . . . . . . <br /> Grading . . . . . . Subdivision Perc. Rate . . . . . . . . . . . . . . . . . <br /> Mobile Home Sanitary . • • , Dry Well . . . . . . ,'^, m <br /> Seepage e TrenchPrivy . . . . . . Building . . . . . . . . . . . . m 19 <br /> Well . . . . . . Well . . . . . . Privy . . . . . . <br /> Subdivision Seepage Bed . . . . . . :Z0 <br /> . . . . . . Other (Specify) , • , , , , <br /> Conditional . . . . . . o \° (n cn <br /> 2. Classificationpp Land Use . . . . . . Q <br /> Zoning Dist. o <br /> w 6. Use (describe exactly, 1 -fam. ' <br /> 3. Lot Size home, motel,etc.) FOR COMMERCIAL USE 0 <br /> 0 <br /> . . t. ft x . . . . . ft. Plans Submitted <br /> . . . .�]�.. . .a,,, � . . sq. ft. Plans Approved . . . . . . <br /> — ------- -------- — — <br /> Fig. A. Location of 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 s <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- :p <br /> tersection, show the intersecting high- <br /> ways and the setbacks required along <br /> them and at the intersection. <br /> �Ir-cr sd A <br /> n � � PERMIT FEES <br /> Subdivision..... $25.00 + $2.00 per lot. tD <br /> 30 � J Land Use................................. $10.00 <br /> ` uildin .................................. 10.00 : J <br /> Sanitary .................................. 35.00 <br /> vWell ........................................ 10.00 <br /> Privy .................................... 5.00 <br /> yEL <br /> .� � ..... .E.- ............ �1 �� <br /> ......................................... <br /> Si ature of Owner or Agent Date Zonin Administrator <br /> InspectionDate ................................................ Inspector ................................................................................................ <br /> Remarks ............................................................................................................................................................ <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 />