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a;,nntt County C Office of Zoning <br /> ,Administrator vir0Ce0 y <br /> o (� <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT v 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a <br /> rfor the work described and located shownere in. The undersigned agrees that all <br /> wok <br /> ' work shall be done in accordance wreith the reyuiremen[s dt the County Zoning Ordinance, F <br /> Sanitation Code, and with all other applicable County Ordinance and the laws and regu- <br /> lations of the Stat qoI WIS in. I c 0 <br /> Owder or Agent (please print) Contractor or Surveyor c — <br /> a ry . <br /> . . . . -AT3 ��. d ,( <br /> I Address . `?.� .�. . . .Address . . . . . . . . . . . . . . <br /> . . . . . . . . . . . . . . . . <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Ph& Phone <br /> � <br /> 7 .�, . - . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ` V g <br /> Plumber WellDriller i S <br /> G ) <br /> Add . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A 0 a <br /> Address Address ' <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . – <br /> Phone � � � �Phonc <br /> 0 <br /> ° 7 <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities I c <br /> Type pLConstruction No. Bathrooms o Z r <br /> 1. Work . . . 1 �A.^!n. ��. . . . . No. Bedrooms ° <br /> New Building . . . . . . Size ft. ft. Septic Tank Size Gals. <br /> -Addition . . . . . Height . . . . . Stories . . . . . . <br /> Sanitary . !.�! Area . . . . . . . I . . . . . . . . . . . 7a.Absorption Field Site: ? <br /> Filling . . . . . . Soil Type . . . . . . ..ext <br /> ' Moving . . . . . . 5. Permits Required Slope .tom <br /> Grading . . . . . . Subdivision Perc. Rate ` <br /> . . . . . . . . . . . . . . . . . ° A <br /> T T <br /> Mobile Home . . . . Sanitary , _ , _ , Dry Well <br /> Priv / BuildingSeepage Trench <br /> Well . .V. Well „� Privy w N t <br /> Subdivision . . . . . . Other (Specify) . . . . . . Seepage bed J. . . . <br /> Conditional ^ A <br /> 2. Classification yt/n Land Use . . . . . . c ° <br /> Zoning Dist. // Ys/ ? <br /> B. Use (describe exac y, 1 to <br /> m <br /> o <br /> 3. Lot Size t i j hoe,motel,etc.) FOR COMMERCIAL USE <br /> r <br /> tx . . . _ . . . ft. Plans Submitted . . . . . . " Sli <br /> . .'�. . . . . . . . . . . .. . . sq. ft. Plans Approved . . . . . . : i ' <br /> __________________________________________________________________ <br /> Fig.A. /, ' Location of proposed structures and i� r <br /> /1v� <br /> existing structures, well, sewage sys- '<: o <br /> terns, roads, etc., should be sketched 1ir I g <br /> X 'T I in Fig. A. Include road setback, side <br /> and back yard dimension and location pw_ ci <br /> and setback from all bodies of water, i� i4J ZI <br /> If property is located at a highway in- <br /> i v B„x(In tersection, Show the intersecting high- ' !( <br /> Dy � � ways and the setbacks required along °\ <br /> t'1 `{' them and at [he intersection. A a� <br /> y PERMIT FEES o <br /> L Subdivision . . . . . . . . . 51 b <br /> Land Use . . . . . . . . 10.00 <br /> Build in9 &-W :p <br /> Sanitary . jSBt7 ¢ <br /> Well <br /> Septic Tank <br /> 10.00 n <br /> Combination Building, Sanitar <br /> and Well <br /> Privy . . . . . . . . . . . . 5.00 ✓I <br /> 7 �� <br /> Signature of Owner or Agent Date i <br /> din <br /> .in1i7straor <br /> Inspection Date 5... 91qq... .......... Inspector 1 / . 1.� <br /> .. <br /> .A. ..._Remarks <br /> ... <br /> ..... <br /> j...all, 12.._a. w�.. Vii......... <br /> eX.6.1p <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary fa ht <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the.percolation test must be attache,? <br /> this application before a permit will be issued. Do not purchase or install a septic tank, downy plumbing or start any bw <br /> ing until a permit has been issued. A permit may be revoked it 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,Admlm Strat <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />