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Burnett County Office of Zoning Administrator V) -0 0 -1 Z <br /> CD C d o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT °• <br /> = v <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a _' o :��_ <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, XCD <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- - <br /> lations of the State of Wisconsin. ° O I <br /> 3 <br /> 1. . . . . . . . . . . cR Ry Gam <br /> .�. . . . Q . . . r. . . . . . . . . . . . . . . . . . . . . . _ CD <br /> Owner or Agent (ple se print) Contractor or Surveyor y <br /> c <br /> R(� C / ` co <br /> 1 . . . . . .6PA . .l!!f SC a <br /> Address Address ; <br /> d <br /> . �.� �/.-.?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . h <br /> Phone Phone <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Plumber Well Driller <br /> 0 <br /> . . . . . . . . . . . . . . . . . . . . <br /> A : n o <br /> ddress Address <br /> 0 <br /> o 1 <br /> Phone Phone CD H <br /> 0 0 <br /> m 0 <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: ' <br /> Type of Construction No. Bathrooms • • • • • • o Z -00 <br /> 1. Work No. Bedrooms 0 CD <br /> New Building Size AAA.` ft. x .. .. . eft. Septic Tank Size Gals. <br /> Addition Height . . . . . Stories . . <br /> 7a.Absorption Field Site: <br /> Sanitary . . . . . . Area . r- <br /> Soil Type . . . . . . . . . . . . . . . . . . ��\ o <br /> Filling <br /> Moving . . . . . . 5. Permits Required Slope . . . . . . . . . . . . . . . . . . . . <br /> Grading . . . . . . Subdivision . . . . . . Perc. Rate . . . . . . . . . . . . . . . . . <br /> Mobile Home . . . . . . Sanitary Dry Well . . . . . . m ( <br /> ' D <br /> Privy . . . . . . Building Seepage Trench . . . . . . `D CD <br /> Well . . . . . . Well . . . . . . Privy <br /> o <br /> Subdivision . . . . . . Other (Specify) . . . . . . Seepage Bed . . . . . . o <br /> Conditional . . . . . . o N N <br /> c CD <br /> 2. Classification Land Use . . . . . . a <br /> Zoning Dist. . . . . . . <' 0 <br /> 6. Use (describe exactly, 1 -fam. y <br /> 3. Lot Size home, motel,etc.) FOR COMMERCIAL USE <br /> ft.x ft. Plans Submitted 0 <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 /> in Fig. A. Include road setback, side <br /> and back yard dimension and location <br /> and setback from all bodies of water. <br /> 14) 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. <br /> PERMIT FEES <br /> Subdivision.....$25.00 + $2.00 per lot. fD <br /> Land Use................................. $10.00 <br /> Building................................... 10.00 <br /> Sanitary .................................. 20.00 <br /> Well ........................................ 10.00 <br /> q Septic Tank ............................ 10.00 <br /> Cf� Privy ....................................... 5.00 <br /> v <br /> 17�W/te Signature of O ner or Agent Zonin inistrator <br /> InspectionDate ................................................ Inspector ................................................................................................ <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 />