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Burnett County a Office of Zoning Administrator N `ate z <br /> M M d 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT <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, a <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- CD ^ <br /> lations of the State of Wisconsin. ° O <br /> 3 :CC. <br /> . . . . . N :oCD <br /> Owner or Agent (please print) Contractor or Surveyor H <br /> c <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 <br /> Address Address a '� <br /> Co <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . :'K) <br /> Phone Phone <br /> lumber Well Driller <br /> �. . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Address Add ess O <br /> o <br /> Zb . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c� <br /> Phone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Phone <br /> 0 " 0 <br /> m 0 <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: ° _° <br /> Type of Construction No. Bathrooms • • . o o 0 <br /> 1. Work No. Bedrooms CD <br /> New Building . . . . . . Size . . . . . ft. x . . . . . . ft. Septic Tank Size Gals. <br /> Addition . . . . . . Height . . . . . Stories . . . . . . <br /> 7a.Absorption Field Site: (, <br /> Sanitary 1i . . Area . . . . . . . . . . . . . . . . . . . r <br /> Filling Soil Type . . .St . . . . . . . . . . .� :� 0 <br /> Slope .r?7.0. . . . . . . . . . . . . . <br /> Moving . . . . . . 5. Permits Required <br /> '+ <br /> Grading . . . . . . Subdivision Perc. Rate . . . . .. . . . . . . . . . . ( I <br /> Mobile Home . . . . . . Sanitary Dry Well r}---4r <br /> Privy . . . . . . Building Seepage Trench <br /> Well . . . . . . Well Privy . . . . . . <br /> Subdivision Other (Specify) . . . . . . Seepage Bed . . . . . . Q <br /> Conditional . . . . . . tl <br /> c <br /> 2. Classification Land Use M <br /> Zoning Dist. / r L <br /> . . . . . < <br /> 6. Use (describe exactly, 1 -fam. HW 0 <br /> 3. Lot Size home, motel, etc.) FOR COMMERCIAL USE <br /> . . . . . . . ft.x . . . . . . . . ft. Plans Submitted . . . . . . <br /> S.7.,Az r•e s. . . sq. ft. Plans Approved <br /> ------------------------------------------------------------------- <br /> Fig. A. Location of proposed structures and <br /> existing structures, well, sewage sys- 0 <br /> tems, roads, etc., should be sketched <br /> in Fig. A. Include road setback, side s <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 <br /> Well ........................................ 10.00 <br /> Privy ....................................... 5.00 <br /> llC . l........... t.:..... ...r .......................................... <br /> .. .............:.............. ................. ........................ <br /> : G � <br /> Signature of Owner or Agent 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 />