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�t710,f <br />Burnett County Office of Zoning AdministratorCn -V o zC <br />APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 CD P <br />TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application fora � '_' o <br />Permit for the work described and located as shown herein. The undersigned agrees that all N <br />work shall be done in accordance with the requirements of the County Zoning Ordinance, 77 <br />Sanitation Code, and with all other applicable County Ordinances and the laws and regu- -o ° <br />lations of the State of Wisconsin. CD a N 2> <br />L .. <br />. 1........ 3 s <br />Owner or Agent (please print)�- J Contractor or Surveyor H 1 ; h CD <br />r m y '\ <br />LCddre ....�... .! ... /. ! 1 AddrJ ............................. <br />ess <br />. ..................................................... . . . : <br />Phone Phone ;(© <br />Plu.m.be..r .............................. Well Driller ............................ :\ ` <br />Address Address <br />° o <br />0 < <br />o <br />Phone Phone CD <br />n — o <br />o <br />DESCRIPTION 4. Building Details 7. Sanitary Facilitiesv <br />Type of Construction No. Bathrooms ...... z Z +� <br />1. Work ...... a..-.........i.. .. Dishwasher ° ° <br />co <br />New Building ...... Size 9..4. ft. x . y� K ft. Garbage Grinder ...... <br />Addition vyN .. Height ..... Stories ...... Autom. Laundry f� <br />Sanitary ...... Area ................... No. Bedrooms <br />Alterations Waste Disposal System w.... ° <br />Moving 5. Permits Required Septic Tank Size Gal s.eX 1`-�- <br />Wrecking ...... Subdivision ...... Absorption Field Site :(n <br />Mobile Home ...... Sanitary Soil Type .................. CD CD <br />Privy ...... Building Slope .................... `D `D <br />V) <br />Well ...... Well ...... Perc. Rate ................. <br />Subdivision ...... Other (Specify) ...... Dry Well o <br />Conditional ...... Seepage Trench <br />C: CD <br />2. Classification Land Privy <br />R0- <br />_• <br />Zoning Dist. Seepage Bed j <br />6. Use (describe exact) fam N' <br />3. Lot Size home, motel, etc.) FOR COMMERCIAL USE ' 0 \` <br />......... ft. x ........ ft. Plans Submitted <br />..... . <br />.... sq. ft. Plans Approved <br />--- rnrn <br />Fig. A. Location of proposed structures and <br />F'% existing structures, well, sewage sys- ^ o <br />1 tems, roads, etc., should be sketched <br />~-� _r in Fig. A. Include road setback, side s <br />a co F () Or and back yard dimension and location ;� a <br />,raj 1 IIVt. and setback from all bodies of water. <br />ay-/d If property is located at a highway in- <br />tersection, show the intersecting high- <br />ways and the setbacks required along <br />f them and at the intersection. <br />_ - PERMIT FEES <br />Subdivision . . . . . . . . . $15.00 l `D <br />_! LL�� Land Use. . . . . . . . . . . 1.00: <br />0 5 % 0 L- /4 rl �'— Building . . . . . . . . . . .5:00 ; V <br />Sanitary . . . . . . . . . . 00 �� t <br />Well . . . . . . . . . . . 5.00 <br />Septic Tank . . . . . . . . . 1.00 <br />Combination Building, Sanitary <br />and Well . . . . . . . . 15.00 <br />............... <br />Signature of Owner or Agent Date Z ing A inistrator <br />InspectionDate................................................ Inspector................................................................................................ <br />Remarks............................................................................................................................................................ <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 />