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Burnett County ' Office of Zoning Administrator <br /> N 0 Z <br /> � <br /> 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT 3 CD j <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a 0 :_C <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 /> CD <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- v a <br /> lations of the State of Wisconsin.U . . . . . . . . . . . . . . . I< P1,61, <br /> . . . . `D <br /> no <br /> o <br /> Owner or Agent (please print) Contractor or Surveyor <br /> C <br /> CD <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> �^ Q <br /> Address Address a � 'S <br /> m S4. <br /> Phone i <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Phone. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> ,! bj". . ' . . . . . . . . . . . . . . . . . . . . .Dri. . <br /> Plumber Well ller �q <br /> . . , . . . . . �? . . . v23 . . . !('.l.1. :� efiry. . . . . . . . . . . . . . . . . . . o_ <br /> Address l dress <br /> CID <br /> 3 <br /> . . . . . . . . . . . . . . . . . e <br /> Phone Phone C <br /> CD o <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: a _V <br /> Type of Construction No z o <br /> . Bathrooms • • /• • • o z _01. Work No. Bedrooms . .. . . . CD <br /> New Building . . . . . . Size . . . . . ft. x . . . . . . ft. Septic Tank Size Gals. <br /> Addition . . . . . . Height . . . . . Stories . . . . . . . , • . . . <br /> Sanitary . . . . . . Area 7a.Absorption Field Site: w �` <br /> Filling . . . . . . Soil Type . . . . . . . . . o <br /> Moving . . . . . . 5. Permits Required Slope . .' .7d.. . . . . . . . . . . . <br /> Grading . . . . . . Subdivision . . . . . . Perc. Rate . . . .`.a'. . . . . . . . . . . <br /> Mobile Home . . . . . . Sanitary ✓_ Dry Well in -n <br /> CD <br /> Privy . . . . . . Building . , , , . . Seepage Trench '� �o <br /> Well Well Privy fn i <br /> . . . . . :uy <br /> Subdivision . . . . . . Other (Specify) . . . . , , Seepage Bed . . . . . . <br /> Conditional . . . . . . cn cn <br /> CD <br /> 2. Classification Land Use . . . . . . s <br /> a '* <br /> Zoning Dist. . . . . . . I o' <br /> 6. Use (describe exactly, 1 -fam. _ <br /> 3. Lot Size home, motel, etc.) FOR COMMERCIAL USE 00 <br /> . . . . . . . . . ft. x . . . . . . . . ft. Plans Submitted . . . . . . <br /> S. . - <br /> 7. . GC4S . . sq. ft. Plans Approved <br /> —————————————————————————————————— ------------ ------------ . : <br /> Fig. A. Location of proposed structures and <br /> existing structures, well, sewage sys : G o <br /> tems, roads, etc., should be sketched <br /> 3 <br /> in Fig. A. Include road setback, side s <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. <br /> PERMIT FEES <br /> CD <br /> Subdivision..... $25.00 + $2.00 per lot. <br /> Land Use................................. $10.00 r <br /> Building................................... 10.E <br /> Sanitary .................................. 5.00; <br /> Well ........................................ 10.00 : - <br /> Privy ....................................... 5.00 <br /> - z....... ........................... ��.......... �G� � ✓ <br /> . .... ............................................... <br /> Signature of Owner r 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 />