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Burnett County Office of Zoning Administratoro <br /> ' o /o <br /> APPLICATION FOR SANITARY — LAND USE*— BUILDING PERMIT °. 3 o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a N <br /> Permit for the work described and located as shown herein. The undersigned agrees that all c4 c <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu a ' <br /> lations of the State of Wisconsin. 3 <br /> d 0 <br /> r; m <br /> j�i0v o .UG.GfiP s' _ I 1 <br /> Owner or Agent (please print) Contractor or Surveyor H <br /> W PAST a :S <br /> Address Address <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . p(� - <br /> Phone Phone 1 <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Plumber / Well Driller <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Address Address o <br /> '7 <br /> � <br /> >1 <br /> Phone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .PhoneM m N r <br /> n 0 o <br /> o <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: Z <br /> Type of Construction No. Bathrooms . • . • . • o Z 0 <br /> 1. Work . . . . . . . . . . . . No. Bedrooms • • ° <br /> New Building Size ft. x .✓ ft. Septic Tank Size Gals. . <br /> Addition Height . . . . . Stories . f . . . . . . . . t <br /> Sanitary Y . Area . . . ./yd.4. .f�' 7a.Absorption Field Site: I 1 <br /> g �. r <br /> Filling . . . . . . Soil Type . . . . . . . . . . . . . . . . . . V1 o <br /> Moving . . . . . . 5. Permits Required Slope . . . . . . . . . . . . . . . . . . . . ° <br /> Grading . . . . . . Subdivision Perc. Rate . . . . . . . . . . . . . . . . . <br /> Mobile Home . . . . . . Sanitary t Dry Well U - m <br /> Privy . . . . . . Building ji, Seepage Trench . . . . . . m �( <br /> WellWell Privy /� 0.1(a fA <br /> :7 <br /> Subdivision . . . . . . Other (Specify) . . . . . . Seepage Bed /. P. .3� <br /> Conditional :} rn <br /> 2. Classification Land Use . . . . . . (}� :S a <br /> Zoning Dist. <br /> 6. Use (describe exactly, 1 -fam. I l �� <br /> 3. Lot Size home, motel, etc.) FOR COMMERCIAL USE ( ° <br /> �l <br /> � .�. . . . ft. x �. . . . ft. Plans Submitted r <br /> sq. ft. Plans Approved • <br /> � --- <br /> Fig' A. Location of proposed structures and <br /> 40 existing structures, well, sewage sys- .S :E <br /> / N tems, roads, etc., should be sketched J� :A <br /> in Fig. A. Include road setback, side " r <br /> and back yard dimension and location <br /> and setback from all bodies of water. 7��o r If property is located at a highway in- <br /> '��� t, tersection, show the intersecting high. <br /> �a � ways and the setbacks required along <br /> them and at the intersection. �\ <br /> 6 <br /> PERMIT FEES <br /> y Subdivision . $15.00 <br /> Land Use . . . . . . . . . . <br /> Building . . . . . . . . . . . 5.0 <br /> F- -61 1dX 3b Sanitary . . . . . . . . . 10.0 <br /> rt Well 5.00 :C <br /> Septic Tank . . . 10.00 <br /> Combination Building, Sanitar v <br /> and Well . . . . . . . . 15.00 <br /> 30 Privy . . . . . . . . . . . . 5.00 Q <br /> 9 <br /> ..... ........ / ...� .... �. .. (//1r�I�� <br /> Si nature o Owner ent . -- • ••••.. • .... <br /> ate Zo 9 inistrator <br /> Inspection Date .4e� p.. ,� f,�!Z„ .... Inspector ........ <br /> Remarks ...7`.,........-, <br /> ............... . <br /> .. ...... ............ ....................................................................... <br /> .......................................................................... . .. . . <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be att <br /> this application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start ai <br /> ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the information convey <br /> with is found to exist. Changes in plans or specifications shall not be made without approval of the Zoning Admit <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVI <br />