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Burnett County Office of Zoning Administrator <br /> rn v O --1 Z <br /> m m m ° ° <br /> APPLICATION FOR SANITARY — LAND USE —•- PUILDING PERMIT �. <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application fora � = 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, 77 <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- - ° <br /> lations of the State of Wisconsin. a <br /> 3 y� <br /> v\ <br /> Owner orrAgent (please print) Contractor or Surveyor <br /> 'S] 7 o x / G . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . a (A <br /> Address Address a <br /> . . <br /> Phone Phone <br /> . . . ber W. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ell D. .riller. . <br /> Plum <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . - <br /> Address Address m 0 / <br /> • .gyp .. < <br /> Phone Phonen H 0 <br /> n „ o <br /> ° <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: ° <br /> Type of Construction No. Bathrooms �• • • o o° ° <br /> 1. Work . . . . . . . No. Bedrooms <br /> New Building X. . Size ft. x .1 :. . ft. Septic Tank Size Gals. J5$.v <br /> Addition . . . . Height Stories <br /> Sanitary X,. . Area . .7.7C) . . . . . . . . . . . . 7a.Absorption Field Site: :gyp :NJFilling Soil Type . . . . . . . . . . . .. © :�I ° <br /> Moving 5. Permits Required Slope . . . . . . . . . . . . . . . . <br /> p <br /> Grading . . . . . . Subdivision Perc. Rate . . . . . . . . . . . . . . . . . <br /> Mobile Home . . . . . . Sanitary ✓ Dry Well <br /> Privy . . . . . . Building • • •✓ Seepage Trench �I <br /> Well . . Well • • , v! Privy a�pp ^� py <br /> Subdivision . . . . . . Other (Specify) . . . . . . Seepage Bed �0. 7 :C/%' :� <br /> Conditional N g <br /> 2. Classification Land Use . . . . . . : 1' a �. <br /> Zoning Dist. (f:�. . < o c, <br /> j 6. Use (describe exactly, - fam. <br /> 3. Lot Size om , motel,etc.) FOR COMMERCIAL USE 0 <br /> J),3. . . . ft. x ft. Plans Submitted . . . . . . <br /> 00. . . . . . <br /> . 43�f:J. . . . sq. ft. Plans Approved . . . . . . <br /> --------------------------------------------------------- <br /> Fig.A. Location of proposed structures and <br /> existing structures, well, sewage sys- ° <br /> tems, roads, etc., should be sketched <br /> in Fig. A. Include road setback, side s <br /> —/ and back yard dimension and location o <br /> �S and setback from all bodies of water. :eros <br /> If property is located at a highway in- <br /> tersection, show the intersecting high- <br /> ways and the setbacks required along <br /> them and at the intersection. <br /> G <br /> ��I(� PERMIT FEES <br /> / 0 Subdivision..... $25.00 + $2.00 per lot. <br /> p[ �� Land Use................................. $10.00 N <br /> ...................... 10.00 <br /> Sanitar .... 35.00 <br /> Well ...................................... 10.00 <br /> Privy ....................................... 5.00 <br /> S's— art <br /> NL� LRKE Ruar' <br /> zc'.... . ... . . .~ ....... ...... �'��./ /............ !:v.l. ..... <br /> C1............ <br /> S11tur of Owner or Agent ate Zoning Administrator <br /> Inspection Date ..7.`.1fP............F/ <br /> ..................... Inspector . . ...... .......�t..5e� .. .. . . <br /> �i <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 />