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Burnett Count <br /> y UT7_L!S A �� D Office of Zoning Administrator <br /> m (D m o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT °. CD 3 <br /> ,TO THE }ZONIrtG 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 y <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, X, CD <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu <br /> latio s .of the to of Wisconsin. 3 <br /> r . . . . . . . . . . . . . . . . . . _ <br /> Owner or Agent (plgase print) Contractor or Surveyor y :� CD <br /> . . . LX� . . . . . . . .X. . . . . . . . . . . . . . . . <br /> Address Address a : <br /> Qj 4 <br /> CD <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . / <br /> Phon Phone V <br /> C1 ' <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Plumber` Well Driller :a <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . J. <br /> Address Address �i 0 o <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> o <br /> Phone Phone y m <br /> m o <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: ° <br /> Type of Construction No. Bathrooms . . • • • • o Z 0 <br /> 1. Work No. Bedrooms ° CD <br /> New Building . . . . . . Size . . . . . ft. x . . . . . . ft. Septic Tank Size Gals. .Yq'o < <br /> Addition Height . . . . . Stories . . . . . . —� <br /> Sanitary . . . . . . Area 7a.Absorption Field Site: <br /> Filling Soil Type . . . . . . . . . . . . . . . . . . � o <br /> . . . . . r <br /> Moving . . . . . . 5. Permits Required Slope <br /> Grading . . . . . . Subdivision . . . . . . Perc. Rate . . . . . . . . . . . . . . . . . 1 <br /> Mobile Home . . . . . . Sanitary �_/ Dry Well . . . . . . CD CD <br /> CD CD <br /> Privy . . . . . . Building Seepage Trench . . . . . . <br /> Well . . . . . . Well . . . , , . Privy <br /> Subdivision Other (Specify) Seepage Bed 6 . . . . . o <br /> Conditional . . . . . . b N N <br /> c CD <br /> 2. Classification Land Use 0 a _ <br /> Zoning Dist. . . . . . . o <br /> 6. Use (describe exactly, 1 -fam. _ <br /> N <br /> 3. Lot Size home, motel,etc.) FOR COMMERCIAL USE 0 <br /> o <br /> . . . . . . . . . ft. x . . . . . . . . ft. Plans Submitted . . . . . . <br /> . . . . . . . . . . . . . . . . . . sq. ft. Plans Approved . . . . . . ;Ci <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 <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- :A <br /> (I� ways and the setbacks required along ? <br /> them and at the intersection. <br /> PERMIT FEES <br /> g Subdivision . . . . . . . . . $15.00 `D <br /> Land Use . . . . . . . . . . . 1.00 <br /> Building . . . . . . . . . . . 5.00 <br /> Sanitary . . . . . . . . . . . 10.00 <br /> Well . . . . . . . . . . . 5.00 <br /> Septic Tank . . . . . . . . . 1.00 <br /> Combination Building, Sanitary <br /> and Well . . . . . . . . 15.00 <br /> Privy . . . . . . . . . . . . 5.00 <br /> � r <br /> .... .....f..... ... ................. ..... •. �..1...7 ..... ... ... . . ... ........./YJ................. <br /> Signature of caner or Agente nin Administrator <br /> InspectionDate ....��'.. .C�.... .. ........ Inspector ............ ................. ....... ... . .............................................. <br /> em a re ......k�-tom......... ^. . ... .......... .............. ........ .......... <br /> // ..... ....�........................................... <br /> ......................... .........................." d.. .......... ....... ....... <br /> �y.. ..... ........ ...................................................................................................................................... <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 />