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. Burnett County <br />Office of Zoning Administrator <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 <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. <br />.. �' sTep X�'Z4.�........... ....... ;!. -. 1 ................. . <br />Owner or ge <br />Ant (pleari Contractor or Surveyor <br />$4X ... A.s' I.... w -e6 rt .... . <br />Address Address <br />....................................Ph.one.................................. <br />Phone LL�� <br />..... <br />T'1 Vin. Well Driller <br />............................. <br />Plumber ti � <br />...res...................................Address................................. <br />Adds <br />....................................................................... <br />Phone Phone <br />DESCRIPTION <br />1. Work <br />New Building <br />Addition <br />Sanitary <br />Filling <br />Moving <br />Grading <br />Mobile Home <br />Privy <br />Well <br />Subdivision <br />4. Building Details 7. Sanitary Facilities: <br />Type of Constrction` No. Bathrooms <br />' No. Bedrooms ... a_ <br />.. Size ..... ft. x ...... ft. Septic Tank Size Gals. <br />Height ..... Stories ...... `� 0 <br />...... Area 7a.Absorption Field Site: <br />2. Classification <br />Zoning Dist. R P_�:A . <br />3. Lot Size <br />0 <br />2 <br />ft. x ........ ft. Plans Submitted ...... <br />.� ��... 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 />o-7 / 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 />tersection, show the intersecting high- <br />11 <br />ways and the setbacks required along <br />them and at the intersection. <br />o <br />/ A' IN 01 1 <br />PERMIT FEES <br />Subdivision . . . . . . . . <br />Land Use . . . . . . . . . . . <br />Building . . . . . . . . . . . <br />Sanitary . . . . . . . . . . . <br />Well . . . . . . . . . . . <br />Septic Tank . . . . . . . . . <br />Combination Building, Sanitary <br />and Well . . . . . . . . <br />Privy . . . . . . <br />4 <br />........................................................................ ..-.. .... <br />� <br />Signatu o Owner or Agent <br />g Date <br />Inspection Date ...��...` ....!..........`.1... Inspector.lr.T-f . .. �..4 <br />c <br />Remarks ...........G��....... ""�� "�"....... ........ <br />t <br />$15.00 <br />1.00 <br />5.00 <br />10.00 <br />5.00 <br />10.00 <br />15.00 <br />5.00 <br />g Administrator <br />// ' . <br />No <br />r, <br />co <br />n <br />0 <br />c <br />0 <br />W. <br />M <br />1 <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 />Soil Type .................. <br />............ <br />5. Permits Required <br />Slope e <br />Subdivision <br />Perc. Rate ................. <br />Sanitary <br />, , . , , , <br />... 4, <br />Dry Well ...... <br />Building <br />Seepage Trench ...... <br />Well <br />Privy <br />Other (Specify) <br />.. , ... <br />Seepage Bed <br />Conditional <br />...... <br />Land Use <br />...... <br />6. Use (describe exact) , 1 - fam. <br />home, motel, etc.) <br />FOR COMMERCIAL USE <br />0 <br />2 <br />ft. x ........ ft. Plans Submitted ...... <br />.� ��... 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 />o-7 / 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 />tersection, show the intersecting high- <br />11 <br />ways and the setbacks required along <br />them and at the intersection. <br />o <br />/ A' IN 01 1 <br />PERMIT FEES <br />Subdivision . . . . . . . . <br />Land Use . . . . . . . . . . . <br />Building . . . . . . . . . . . <br />Sanitary . . . . . . . . . . . <br />Well . . . . . . . . . . . <br />Septic Tank . . . . . . . . . <br />Combination Building, Sanitary <br />and Well . . . . . . . . <br />Privy . . . . . . <br />4 <br />........................................................................ ..-.. .... <br />� <br />Signatu o Owner or Agent <br />g Date <br />Inspection Date ...��...` ....!..........`.1... Inspector.lr.T-f . .. �..4 <br />c <br />Remarks ...........G��....... ""�� "�"....... ........ <br />t <br />$15.00 <br />1.00 <br />5.00 <br />10.00 <br />5.00 <br />10.00 <br />15.00 <br />5.00 <br />g Administrator <br />// ' . <br />No <br />r, <br />co <br />n <br />0 <br />c <br />0 <br />W. <br />M <br />1 <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 />