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Burnett County 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 />lation§ of the State of Wi c nsin. <br />W/.�11'�arr .�.. �..:�. . . ..... 1-�....................... <br />Owner or Agent (please print) Contractor or S�ireey�er <br />a ,. . <br />Address _ b Address <br />.............................. <br />....................................... <br />Phone Phone <br />............................ <br />Plumber Well Driller <br />....................................................................... <br />Address Address <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 />2. Classification <br />Zoning Dist <br />4. Building DFtails <br />Type of Cbrist�cji,Q� , <br />,,..! .?c ..... <br />Size, ft. x , (!f ft. <br />Height ..... Stories ...... <br />Area ................... <br />7. Sanitary Facilities: <br />No. Bathrooms • • . <br />No. Bedrooms ...... <br />Septic Tank Size Gals. <br />Cui <br />o `a. <br />a <br />m <br />CD <br />c <br />C <br />o ^' <br />CD <br />O, <br />� <br />y <br />m <br />a <br />c� <br />i <br />t <br />C <br />m <br />n <br />o <br />CD <br />n <br />< <br />rt <br />r <br />o <br />0 <br />m <br />-a <br />z <br />o <br />o <br />+ 7 <br />.-6 <br />o �� <br />m m <br />m Co <br />CD CD <br />A <br />6. Use (describe exactly, 1 fam., y' <br />3. Lot e home, motel, etc.) FOR COMMERCIAL USE f� <br />.. �... ft. x r...... , ft. if ��` Plans Submitted ...... <br />.................. sq. ft. !� Plans Approved ' <br />---------------------------------v-- .....? <br />��_ Fig. A. Location of proposed structures and <br />:. <br />existing structures, well, sewage sys-sketched <br />{ o <br />terns, roads, etc., should be sketched <br />in Fig. A. Include road setback, side <br />and back yard dimension and location -o <br />and setback from all bodies of water. <br />If property is located at a highway in- <br />tersection, show the intersecting high- <br />ways and the setbacks required along :\ <br />them and at the intersection. j <br />PERMIT FEES <br />T�0 0 <br />5. Permits Required <br />Subdivision ...... <br />Sanitary <br />Building <br />Well ...... <br />Other (Specify) ...... <br />Conditional ...... <br />Land Use ...... <br />Signature of caner or Agent <br />Inspection Date .......................................... <br />7a.Absorption Field Site: <br />Soil Type .................. <br />Slope................. .. <br />Perc. Rate ............. ... <br />Dry Well ..... <br />Seepage Trench .... <br />Privy ...... <br />Seepage Bed <br />Subdivision . . . . . <br />. . . <br />and Use . . . . . . <br />Building <br />. . . . . <br />. . . . . . <br />. . . . <br />Sanitary . . . . . . <br />. . . . <br />Well . . . . . . <br />. . . . <br />Septic Tank . . . . <br />. . . . • 10.00 <br />Combination Building, <br />Sanitary <br />and Well . . . . <br />. . . . 15.00 <br />Privy . . . . . . . . . . . . 5.00 <br />Date <br />Inspector ................. <br />1 ,( <br />oning,Adm inistrator <br />............................................................................ <br />Remarks............................................................................................................................................................ <br />........................................................................................................................................................................................ <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 />