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Burnett County Office of Zoning Administrator,/ l Ct))' <br /> M MIb 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ° <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application fora 0 o <br /> Permit for the work described and located as shown herein. The undersigned agrees that all d N <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 ° <br /> a i s of the State of Wisconsin. 3 0 <br /> caner oeAq t �pl�a�se/p rint) Contractor or Surveyor c I <br /> CD <br /> Address S T�p0 Address Q � <br /> .3..3.E . . . . . . . . . . . . . . . . . . . . . . . . . . . . � 1 � . <br /> Phone Phone <br /> I \ pz� <br /> Plumber <br /> Well Driller <br /> Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Address . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . m G) <br /> ° o <br /> h < <br /> o' <br /> Phone Phone � • • • � • • • • CD y r <br /> — o :1 <br /> CD 0 <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: ° <br /> Typ of Construction No. Bathroomsfe <br /> o Z < <br /> 1. Work �G! � .. . . . . . . . . . . No. Bedrooms ° <br /> New BuildingT y p �. <br /> .�. Size �.y ft. x . .�. . ft. Septic Tank Size G <br /> Addition . . . . . . Height/.'.�!j t ries . .�. . . � \�� <br /> Sanitary . . . . . . Area . . ..5. . . . . . . . . . 7a.Absorption Field Si :V� ' <br /> Filling Soil Type r <br /> YP o <br /> CD <br /> Moving 5. Permits Required Slope Grading Subdivision Perc. Rate <br /> . . . . . <br /> Mobile Home . . . . . . Sanitary , , , , ,', Dry Well - - <br /> Privy . . . . . . Building �/, Seepage TrenchfD CD <br /> Well . . . . . . Well Privy Subdivision . . . . . . Other (Specify) . . . . . . Seepage Bed O <br /> o ' <br /> Conditional . . . . . . CD � cn cn <br /> 2. Classification yO Land Use . . . . . . ( o 0 <br /> Zoning Dist. /to . L o <br /> 6. Use (describe exactly, 1 -fam. <br /> 3. Lot Size home, motel,etc.) FOR COMMERCIAL USE ° <br /> `d�. . . ft. x `Vl ft. Plans Submitted . . . . . . <br /> . . . . . ' I 0.0.0 . . sq. ft. Plans Approved . . . . . . <br /> ----------------------------/-------------------------------------- <br /> Fig. A. Location of proposed structures and <br /> existing structures, well, sewage sys o <br /> tems, roads, etc., should be sketched <br /> in Fig. A. Include road setback, side <br /> and back yard dimension and location a' <br /> �6 q a, and setback from all bodies of water. <br /> —. If property is located at a highway in- w ;C' <br /> tersection, show the intersecting high- ' <br /> ways and the setbacks required along <br /> them and at the intersection. <br /> PERMIT FEES <br /> rt Subdivision . . . . . . . . . $4,§-N m <br /> I <br /> yyYLy Land Use . 00 :vl <br /> Building . . . . . . . . 0 <br /> Sanitary . . . . . . . . <br /> 4-040 <br /> Well . . . . . . . . . . ® r \ <br /> 7 �o Septic Tank . . . . . . . . • 10.00 <br /> Combination Building, Sanitary <br /> and Well . . . . . . . . •&pW % <br /> Privy . . . . . . . . . . . . 5.00 <br /> ............tN.`�''[......... .. ....c?..1•7.... .rl........ . <br /> st <br /> ra.ti ............Signature f Owner or Agent Date Z qdm* nirator <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 />