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Burnett County Office of Zoning AdministratorCD <br />APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT <br />TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a <br />Permit for the work described and located as shown herein. The undersigned agrees that all d y <br />work shall be done in accordance with the requirements of the County Zoning Ordinance,77' CD <br />Sanitation Code, and with all other applicable County Ordinances and the laws and regu- _a <br />lations of the State of Wisconsin. a <br />�� _ r+ <br />CC.. Y. t!? i✓.O. ....../Ct .... "m <br />Owner or Agent (please print) ell� Contractor or Surveyor y <br />C: <br />m <br />AddrK...� .. ............................................ <br />Address CLa <br />Phone Phone <br />C l <br />Plumber........................ <br />Well Drille`r'•� <br />. dress ............................ <br />Address .................................... <br />Address <br />........................................ M <br />Phone Phone m <br />0 <br />DESCRIPTION 4. Building Details 7. Sanitary Facilities ' <br />Type of Construction No. Bathrooms ..... Z Z <br />1. Work ........................ Dishwasher 0 o <br />New Building Size ..... ft. x ...... ft. Garbage Grinder ...... <br />Addition .... Height ..... Stories ...... Autom. Laundry ...... <br />Sanitary ...... Area ................... No. Bedrooms ..... <br />Alterations ...... Waste Disposal System .. .. <br />Moving ...... 5. Permits Required Septic Tank Size Gals. ..... . <br />Wrecking ...... Subdivision ...... Absorption Field Site <br />Mobile Home ...... Sanitarym T <br />Soil Type CD CD <br />Privy Building / SlopeCD <br />� <br />. 0 <br />v <br />Well Well .. Perc. Rate <br />Subdivision ...... Other (Specify) ...... Dry Well o <br />Conditional ...... Seepage Trench <br />I <br />2. Classification Land ...... Privy . , , • . <br />Zoning Dist. ...... Seepage Bed <br />6. Use (describe exactly, 1 - fam. <br />3. LozA/ home, motel, etc.) FOR COMMERCIAL USE <br />�.. ft. x .1;3 <br />/.ft. Plans Submitted ...... <br />.................. sq. ft. Plans Approved ...... <br />--------------------------------------------- <br />Fig. A. Location of proposed structures and <br />existingstructures, well, sewage sys- <br />tems, roads, etc., should be sketched <br />in Fig. A. Include road setback, side <br />and back yard dimension and location <br />and setback from all bodies of water. <br />If property is located at a highway in - <br />1 '2 tersection, show the intersecting high- <br />ways and the setbacks required along <br />�-^ f them and at the intersection. <br />Ld <br />PERMIT FEES <br />Subdivision <br />$15.00 <br />Land Use . . . . . . . . . . . <br />1.00 <br />Building <br />5.00 <br />Sanitary . . . . . . . . . . . <br />10.00 <br />Well . . . <br />Septic Tank <br />`'f--�0 <br />Combination Building, Sanitary <br />and Well . . . . . . . . <br />15.00 <br />..........:4C.�.r ..�..!......... ....... <br />Signature of Owner or Ag <br />Inspection Date ............................................... <br />Remarks....................................... <br />0 —I Z <br />W 0 0 <br />CD <br />o <br />0 <br />O <br />� nn11 <br />0 <br />J <br />� o <br />o <br />H 0 <br />o <br />o <br />0 <br />CDCD <br />r- <br />0 <br />Date onin� inistrator <br />Inspector................................................................................................ <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 />