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Burnett County Office of Zoning Administrator on CIVMIA <br /> o —I Z. <br /> (D cod 0 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ° 3 <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 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- _0 a <br /> lations of the State of4., onsin. a —1 i� ' <br /> d O <br /> Owner or Agent (please print) Contractor or Surve or H `� <br /> CD i <br /> V <br /> Address / Address . . . . . . . . . . . . . . . . <br /> Phone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Phone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . c <br /> Plumb rV- 1Z Well Driller <br /> . . . . s. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Addres Address 0 o , <br /> f <br /> Phone Phone (D H r <br /> 0 <br /> 0 <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: <br /> Type of Construction No. Bathrooms • • • • • • o Z <br /> 1. Work . . . . . . . . . . . . . . . . . . . . . . . . No. Bedrooms . . . . . . m <br /> New Building . . . . . . Size . . . . . ft. x . . . . . . ft. Septic Tank Size Gals. \ :� <br /> Addition Height . . . . . Stories . . . . . . <br /> Sanitary . . . . . . Area 7a.Absorption Field Site: � <br /> Filling . . . . . . Type . . . . . . . . . . . . . . . . . . 0 <br /> Moving . . . . . . 5. Permits Required Slope . . . . . . . . . . . . . . . . . . . . NS <br /> Grading Subdivision / Perc. Rate . . . . . . . . . . . . . . . . . <br /> Mobile Home Sanitary i/ Dry Well CD � <br /> Privy . . . . . . Building Seepage Trench . . . . . . `D `D <br /> Well Privy <br /> Well l <br /> . r r <br /> Subdivision Other (Specify) . . . . . . Seepage Bed <br /> Conditional ; to cn <br /> 2. Classification Land Use . . . . . . 0 <br /> Zoning Dist. . . . . . . ° o' <br /> 6. Use (describe exactly, 1 -fam. <br /> 3. Lot Size home, motel,etc.) FOR COMMERCIAL USE 0 <br /> 0 <br /> . . . . . . . . . ft. x . . . . . . . . ft. Plans Submitted . . . . . . <br /> . . . . . . . . . . . . . . . . . . s . ft.q 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 /> 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 . . . . . . . . . $15.00 m <br /> Land Use . . . . . . . . . . . 1.00 <br /> Building . . . . . . . . . . . 5.00 <br /> Sanitary . . . . . . . . . . . 10.00 <br /> Well . . . . . . . . . . . 5.00 <br /> Septic Tank . . . . . . . . . 1000 <br /> Combination Building, Sanitary <br /> and Well . . . . . . . . 15.00 <br /> Privy . . . . . . . . . . . . 5.00 <br /> ..................:g.......... . ................. ��T, <br /> Signature of Owner or Agent <br /> Da Zoni ministrator <br /> r <br /> Inspection Date .ate?........ <br /> //. ...`... y�........ Inspector .. ... ..... %h�'��'f.. .... ....: ....'............................ <br /> Remarks 0l.�, G .... .. <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 />