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Burnett county Office of Zoning Administrator cn -a o -1 Z <br /> m m o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT °. 3 <br /> ° <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Wi N <br /> Permit for the work described and located as shown herein. The undersigned agrees that all C <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, vCL <br /> M <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- a <br /> lationnss of the State of Wisconsin. / 3 <br /> Own or Agent (please print) / Contractor or Surveyor H i <br /> / q y <br /> -�. <br /> . . . . . . . . . . . . . . . . . . . <br /> Address a ' <br /> Add ess <br /> � ` N <br /> Phone Phone ;N r <br /> Well Driller <br /> Plumbe � •,� :�, <br /> p <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Address <br /> Address ,". ° :[ <br /> o <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Phone 0 <br /> Phone ° � <br /> �. o <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: � �* <br /> Type,pi,Construction No. Bathrooms o Z �0 rg <br /> y� o <br /> 1. Work . . . . . .!�r9�4�. . - lC�t.'�✓` No. Bedrooms a- • , <br /> New Building . . . . . . Size . . . . . ft. x . . . . . . ft. Septic Tank Size Gals. < <br /> 7.� <br /> Addition . . . . . . Height . . . . . Stories . . . . . . : <br /> Sanitary 7a.Absorption Field Site: 1` m Area Soil Type <br /> Filling . • • . i <br /> r <br /> i <br /> Moving 5. Permits Required Slope ;C <br /> Grading Subdivision . . . . . . Pere. Rate m -n :�, <br /> Mobile Home . . . . . . Sanitary Dry Well . . . . . . m m <br /> Privy Building Seepage Trench <br /> fo <br /> Well . . . . . . Well . . . . . Privy <br /> f O Q, :P <br /> Subdivision Other (Specify) Seepage Bed '•� �y c <br /> Conditional . . . . . . cn N <br /> c m <br /> 2. Classification Land Use <br /> I <br /> CL "• <br /> Zoning Dist. . . . . . . ;F 0 <br /> 6. Use (describe exact) 1 -fa ^ <br /> 3. Lot Size home, motel,etc.) FOR COMMERCIAL USES <br /> ft. x . . . . . . . . ft. Plans Submitted . . . . . . <br /> / <br /> . . .Yl. . . 'i-•. . sq. ft. Plans Approved . . . . <br /> ------------------ --------------- --------- P------------ <br /> Fig. A. Location of proposed structures and y <br /> existing structures, well, sewage sys- o <br /> Vt- tems, roads, etc., should be sketched <br /> in Fig. A. Include road setback, side <br /> and back yard dimension and location ' -0 <br /> and setback from all bodies of water. <br /> If property is located at a highway in- <br /> c , <br /> tersection, show the intersecting high. <br /> p��' r(� tv�S ways and the setbacks required along i <br /> I0 them and at the intersection. <br /> z <br /> PERMIT FEES 3 <br /> LO <br /> Subdivision.....$25.00 + $2.00 per lot. m <br /> Land Use................................. $10.00 <br /> \ i <br /> Building,.........wwu.0............. 19�p 1 <br /> \J, Sanitary ........... <br /> IVppWell ...............0..........0............. 10.00 <br /> A) Septic Tank ...........................0 10.00 <br /> Privy ....................................... 5.00 <br /> e <br /> ....................................... .... ....................... .(1 8�-�-tom....................... <br /> Signature f Owner or Agent Date1 Zoning Administrator <br /> �' C7 �/► <br /> Inspection Date.1.. <br /> ...................................... ... Inspector .. <br /> ... ....... <br /> Remarks .... r�!L4�....� � 1.0... ... .... ...............�tl� _'' 01 <br /> c..-� Lje <br /> .............. <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary faciliti <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached <br /> this application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any buil <br /> ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed her <br /> with is found to exist. Changes in plans or specifications shall not be made without approval of the Zoning Administrate <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />