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Burnett County 9 W -0 o --1 Z <br /> Office of Zoning Administrator / <br /> CD CD d 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT °. CD <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a 0 <br /> Permit for the work described and located as shown herein. The undersigned agrees that all H a <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, 27 CD `C <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- _ 0 <br /> lations of the State of Wisconsin. <br /> CD <br /> Owner or Agent (please print) Contractor or Surveyor N <br /> / ' c <br /> o_ <br /> xz <br /> Address Address a <br /> Phone Phone <br /> Plumber Well Driller <br /> �. o <br /> n . . �. . . . . .►.�.o . �-J�`. . s-� . . . . . . . . . . . . . . . . . . . . 3 <br /> Address Address 0 o <br /> 416L .� .`7(2.0 „3. . . . . . . . . . . . . . . . . . . . � � 0 - <br /> Phone Phone <br /> ° <br /> m 0 <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: <br /> Type of Construction No. Bathrooms o z <br /> 1. Work . . . . . . . . . . . . No. Bedrooms • • • ° <br /> New Building Size . . . . . ft. x . . . . . . ft. Septic Tank Size Gals. < <br /> Addition . . . . . Height . . . . . Stories . . . . . . . . . . . . <br /> Sanitary rr Area 7a.Absorption Field Site: (1 <br /> Filling . . . . . . Soil Type . ._c�Ci !�. . . . . . . . '�l o <br /> Moving . . . . . . 5. Permits Required p C. . °C� \ <br /> Sloe 6.?67 . . . . . . . . . . . . 1 : <br /> Grading . . . . . . Subdivision Perc. Rate . . . . . . . . . . . . . . . . - T r` <br /> Mobile Home Sanitary �/, Dry Well CD <br /> Privy . . . . . . Building Seepage Trench . . . 7 `D <br /> Well . . . . . . Well . . . . . . Privy . . . . . . W <br /> Subdivision . . . . . . Other (Specify) <br /> . . . . . Seepage Bed . . . . . . :UO <br /> Conditional . . . . . . N <br /> Cn <br /> rz CD2. Classification Land Use . . . . . . <br /> Zoning Dist. . . . . . . a <br /> o• <br /> 6. Use (describe exactly, 1 -fam. <br /> Ky <br /> 3. Lot Size home, motel,etc.) FOR COMMERCIAL USE ` ° <br /> . . . . . . . . . ft. x . . . . . . . . ft. Plans Submitted . . . . . . �L <br /> . . . . . . . . . . . . . . . . . . sq. ft. Plans Approved . . . . . . <br /> --------------------- ---------------------------- ------------ <br /> Fig. <br /> Location ofproposed 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 /> 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. `D <br /> Land Use................................. $10.00 <br /> Building................................... 10.00 <br /> Sanitary 35. E <br /> Well ........................................ 10.00 <br /> Privy ....................................... 5.00 <br /> z., <br /> .....�. <br /> Signature of Owner orZnt Date Zoning Administrator <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 />