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Burnett County Office of Zoning Administrator c, v o --1 Z <br /> m m 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT D. 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a '_ 0 ;�nl <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, <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- <br /> lations of the State of Wisconsin. ` a <br /> lI4..0M.A5 .W.,. .S t3c�t I�. . . . . . — <br /> s <br /> . . . . . . . . . . . �. . . . . . . . . . . . . . . . . . . . . c ° ; <br /> Owner or Agent (please print Contractor or Surveyor H <br /> i` <br /> 2724? . G.A9PANA!- .fes!-AQFt. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . :A <br /> Address Address W q r 0- •� <br /> 0.-'.3 . . . . . . . . . . . . . . . . . .(vl. <br /> Phone Phone <br /> . . . � .735. � . .'�. .-. . . . . . . � - <br /> Plumber. . . . • • • • - • • - - Well Driller <br /> a . ' <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .� - :�- <br /> Address Address n o <br /> ('o. . . . . I. . :oma, n <br /> . . . . . . . . . .I. . . . . . . . . . . . . 1 <br /> Phone Phone . . . ,\ 0 N r <br /> 0 <br /> m o <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: - 9 v <br /> r Type of Construction No. Bathrooms o Z 0 <br /> 1. Work . .: .CQ!*.n '?. . . . . . . . . . No. Bedrooms . . . . . . <br /> New Building . . . . . . Size fly. . ft. x .3. p. ft. Septic Tank Size Gals. . . ;�. •� <br /> Addition . . . . . . Height . . . . . Stories . . . . . . J,a'.00� \ �• <br /> :qj <br /> Sanitary . . . . . . Area 7a.Absorption Field Site: <br /> p <br /> r <br /> Filling . . . . . . Soil Type . . . . . . . . . . . . . . . . . . o <br /> a <br /> Moving . . . . . . 5. Permits Required Slope . • " " " " " " " " " <br /> Grading . . . . . . Subdivision . . . . . . Perc. Rate <br /> Mobile Home . . . . . . Sanitary ( Dry Well . . . . . . m h Ti,. <br /> Seepage Trench . . . . . . `° f0 <br /> Privy. . . . . . . Building (� fy fA <br /> Well . . . . . . Well Privy o <br /> Subdivision . . . . . . Other (Specify) • • • . . . Seepage Bed <br /> Conditional . . . . . . \6 -0 <br /> 2. Classification q d Land Use . . . . • . <br /> Zoning Dist. <br /> 6. Use (describe exact) <br /> 3. Lot S'ze home, motel,etc.) FOR COMMERCIAL USE U 0 <br /> �. . . ft. xft. Plans Submitted . . . . . . :n <br /> sq. ft. Plans Approved . . . . . . ,�CI :C <br /> V if cn <br />-------- -- ------ <br /> . ? <br /> Fig. A. Location of proposed structures and <br /> ROAD existing structures, well, sewage sys- 0 <br /> tems, roads, etc., should be sketched�... <br /> 100 FT in Fig. A. Include road setback, side <br /> and back yard dimension and location _ 9 <br /> and setback from all bodies of water. :- i <br /> If property is located at a highway in- <br /> tersection, show the intersecting high-(j <br /> DRAIN ways and the setbacks required along i � �� <br /> FIELD them and at the intersection. :a <br /> :C <br /> 12 FT {� SEPTIC- PERMIT FEES <br /> TANK <br /> N�� Subdivision..... $25.00 + $2.00 per lot. <br /> t sand Use ................................ $10.00 <br /> DECK1G Building................................... 10.00 <br /> E <br /> BLDG. Sanitary .................................. 20.00 <br /> QSFT. ell .......................... 10.00 <br /> ,$ I SLOPE SePank .. 10.00 <br /> cKANGE Privy ....................................... 5.00 <br /> qF5 <br /> HIGgAVER <br /> /%A'SE . z3-�1 ..��.. ... . ...................... <br /> ignature of Owner or Agent Date ZoningAdministra or <br /> InspectionDate .................4.......................4...... Inspector ................................................................................................ <br /> Remarks ............................................................................................................................................................ <br /> ................................................................. .....-.......... .... .7.................................a..�. . .................................................. <br /> --a� gC124_3 - ..... .................................................C7 <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 /> .r ' <br />