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Burnett County Office of Zoning Administrator m 9 0 z <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 9 3 gs <br /> :v <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a _ o , :N <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 "a ' <br /> la tions of the S1;tte of ISCOnSin. 3 <br /> } m <br /> Ow er or Az <br /> Agent ease print) Contractor or Surveyor ' :� <br /> �C' v .(K,I.✓PY�. Th.u. . . . . . . . . �t•. �. . 13c�n .17 . l�Qhsftseh/j�c. _ <br /> A dress Address c <br /> . 3 �J <br /> . . . 7. . . . . . . . . . . . . . . . . . . . . . . . . � . . . . . . . . . . . . . . . . . . . . . . . . . . n: Y <br /> Phone Phone <br /> Plumber Well Driller <br /> ai i i <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> O <br /> Address Address O <br /> <: o <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . a: a <br /> Phone Phone �: r <br /> 0 <br /> es: o' <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: a oO v <br /> Zype of Con�(tryycl!ionrr No. Bathrooms ^Z o <br /> 1. Work 4./!1,¢17:T?♦<+.h. .I. .N'.h>P No. Bedrooms . . . . �. o z <br /> c <br /> New Building . . Size . .� ft. x . , ft. Septic Tank Size Gals. /.Ono o: <br /> Addition . .1i Height (. . . . . . . . . . <br /> g .� . Stories . o: <br /> Sanitary . . . . . . Area 7a.Absorpfion Field Site: <br /> . . . . . . . . . . . . . . . . . . . Soil Type . . . . . . . . . . . . . <br /> Filling . .. . . . <br /> Moving . .. . . . 5. Permits Required Slope <br /> Grading . .. . .. Su at ivisioo Pere. Rate .. . . . . . . . . . . . . . . . <br /> Mobile Home Sanitary Dry Well <br /> Privy . .. . . . Building Seepage Trench . . . . . . <br /> Well . . . . . . Well ! Privy y . . . . . . <br /> Subdivision . . . . . . Other (Specify) . . . . J Seepage Bed <br /> 0 <br /> Conditional . . . . . . o I• � N <br /> to <br /> 2. Classification Land Use . . <br /> Zoning Dist. 7!R�. t _�— < o <br /> 6. Use (describe exactly, 1 -faro <br /> 3. Lot Siz '''' rhe e, motel,etc.) (� - FOR COMMERCIAL USE ivy.' ° �! <br /> �. �5ae'_ . _ . ft. Ft oof �1ivIIVy Kv+� Plans Submitted <br /> sq. ft. 0 Plans Approved . . . . . . (S �) <br /> _ _______________________________________________ <br /> Fig. <br /> A. Location of proposed structures and <br /> ZZ existing structures, well, sewage sys o <br /> {'�' tems, roads, etc., should be sketched :o £ <br /> 1 <br /> 1 1 in Fig. A. Include road setback, aid. <br /> L and back yard dimension and locationtr. Ti <br /> ✓"' and setback from all bodies of water. <br /> I If property is located at a highway in- <br /> El <br /> n- iW <br /> `� tersection, show the intersecting high <br /> OI , <jya ways and the setbacks required along <br /> 1 E�1f them an it at the intersection.' <br /> I <br /> ( < A 1 <br /> ao PERMIT FEES M1 <br /> Subdivision..... $25.00 + $2.00 per lo[. . <br /> La se...................:............. $10.00 \ <br /> t Buildin 10.00 <br /> Z l Sanitary .................................. 35.00 1 <br /> Well .. ............... 10.00 i <br /> Privy ....................................... 5.00 <br /> _... <br /> Signature <br /> of Owner or Agent Date Zoning Administrator <br /> InspectionDate ............................_......_.._...._ Inspector ........................................................... .................................... <br /> Remarks ......................_......._................. ......................................................................................................... <br /> .............................................................................. <br /> ............................................................................... <br /> ................................................................................................................................................................................................ <br /> NOTE: A preliminary site inspection must be made and site approval_granted on all structures involving sanitary facilities <br /> m <br /> before construction can begin. In the case of sewerage disposa(systes,'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 of start any build- ' <br /> ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed herr <br /> with is found to exist. Changes in plans or specifications shall not be made without approval of the Zoning Administratm. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br /> i J- <br />