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cam- c - <br /> Burnett County Office of Zoning Administrator N 12 o H z <br /> CD CD d 0 o <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT �• CD <br /> ei <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a H o <br /> Permit for the work described and located as shown herein. The undersigned agrees that all 11, N • <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, 7- C f <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- - °. I <br /> lations of the State of Wisconsin. C-3 fa) ii O <br /> Owner or Agent (please print) Contractor or Surveyor y <br /> c <br /> 1-3 IUCD <br /> 011 11 ? V 11) veY 1���-iisCvs a "`� <br /> .\1 'N\ <br /> Address Address a N% <br /> q 2_ - 76 9 g CD <br /> Phone Phone �, \� <br /> f <br /> Plumber Well Driller ,� <br /> O • V _ <br /> Address Address o. o .� <br /> 1. <br /> o ,. <br /> Phone Phone <br /> m ,, r <br /> C) ,-. 0 <br /> CD o <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: - 73 <br /> Typee of Cons tion No. Bathrooms o z °° \ <br /> 1. Work / . . /".1' 4 � No. Bedrooms ° <br /> New Building `' Size ,..j ft. x 7`v ft. Septic Tank Size Gals. k. <br /> Addition Height Stories <br /> Sanitary Area 7a.Absorption Field Site: N r <br /> Filling Soil Type o <br /> Moving 5. Permits Required <br /> Slope <br /> Grading Subdivision Perc. Rate <br /> Mobile Home Sanitary Dry Well CD-nm <br /> Privy Building Seepage Trench CD <br /> CD <br /> PI <br /> Well Well Privy t� <br /> Subdivision Other (Specify) Seepage Bed oo ,k ,•>s' <br /> Conditional (1) N <br /> c CD <br /> 2. Classification Land Use o- 0 <br /> Zoning Dist. < - <br /> 6. Use (describe exactly, 1 -fam. <br /> 3. Lot Sizehome, mo I,etc.) FOR COMMERCIAL USE ° <br /> ft. x W"... ft. Plans Submitted <br /> sq. ft. Plans Approved <br /> _ n <br /> oo t C <br /> d Fig .A. Location of proposed structures and A i ,J <br /> existing structures, well, sewage sys- �'� <br /> tems, roads, etc., should be sketched <br /> in Fig. A. Include road setback, side _ o- <br /> and back yard dimension and location 'a' <br /> and setback from all bodies of water. I <br /> y,4t-L 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 /> -VPM3 PERMIT FEES <br /> oo Subdivision $25.00 + $2.00 per lot. <br /> �+ Land Use $10.00 <br /> y+` t� Building 10.00 <br /> Sanitary 20.00 <br /> � / <br /> Well 10.00 <br /> 404.0,e-17 c'19. D --- 1 a()IA D 36•-y' Privy 5.00 <br /> . .. . <br /> fir <br /> ,7)Z)G}2ie.eel Yr, i v e, - -2- - 71 <br /> Signature of Owner or Agent Date 1 /?-( fZoni ministrator <br /> Inspection Date Inspector <br /> Remarks <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 />