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Burnett County Office of Zoning Administrator cnl �� i'J o� z <br /> m m d O <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ° CD <br /> TO THE ZONING 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 <br /> Work shall be done in accordance with the requirements of the County Zoning Ordinance, CD <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- -0 <br /> lations of the State of Wisconsin. ov <br /> . . . . . . . . . . ;` rF <br /> � g <br /> Owner or Agent (please print) Contractor or. Surveyor N ? `�° <br /> CD <br /> j ress . . . . . . . . . . . . . . . . r. . . Y.� nr crr. . P . . . . . . . . .. . .. . <br /> Add Q \ <br /> Address ` <br /> m <br /> Phone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Phone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v <br /> Plumber Well Driller <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Address Address :s <br /> o <br /> o <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> :� <br /> Phone Phone N r' <br /> 0 o <br /> CD o <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities <br /> Type).LA Construction No. Bathrooms . . . . . . z z o <br /> 1. Work . . . . . Dishwasher o <br /> New Building . . . . . . Size . . . . . ft. x . . . . . . ft. Garbage Grinder . . . . . . <br /> Addition . . . . . . Height . . . . . Stories . . . . . . Autom. Laundry -- <br /> Sanitary C�. Area . . . . . . . . . . No. Bedrooms <br /> �\ o <br /> Alterations . . . . . . Waste Disposal System . . ✓" ,Y <br /> Moving . . . . . . 5. Permits Required Septic Tank Size Gals. <br /> Wrecking . . . . . . Subdivision . . Absorption Field Site ' <br /> Mobile Home . . . . . . Sanitary Soil Type . . . .`S`Y. . . . w CD <br /> Privy . . . . . . Building . . . . . . Slope . . . . . . . . . . . . . . . . . . . . cD (D "— <br /> Well I <br /> . . . . . Well . . . . . . Perc. Rate . . . . . . . . . . . . . . . . . o <br /> Subdivision . . . . . . Other (Specify) . . . . . . Dry Well _ <br /> 0 <br /> Conditional . . . . Seepage Trench - � C <br /> 2. Classification Land . . . . . . Privy . . . . 0- <br /> Zoning Dist. . . . . . . Seepage Bed /.d. .7 4 ~ o <br /> 6. Use (describe exact) 1 -fam. <br /> 3. Lot Size home, motel, etc.) FOR COMMERCIAL USE ° <br /> .�. . . ft. x V.�. . ft. Plans Submitted . . . . . . <br /> . . . . . . . . . . . . . . . . . . sq. ft. Plans Approved . . . . . . <br /> <t <br /> —————————————————————————————— ---- -------- ————— ------- <br /> Fig. A. Location of proposed structures and <br /> existing structures, well, sewage sys- 0 <br /> tems, roads, etc., should be sketched N <br /> in Fig. A. Include road setback, side <br /> and back yard dimension and location <br /> and setback from all bodies of water. <br /> 1 ff q1 I If property is located at a highway in- ^ w <br /> I� <br /> tersection, show the intersecting high- <br /> ways and the setbacks required along o- <br /> I them and at the intersection. \ i <br /> a <br /> PERMIT FEES <br /> Subdivision . . . . . . . . . $15.00 fD <br /> Land Use . . . . . . . . . . . 1.00 <br /> Building 5.00 <br /> Li M`F Sanitary . . . . . . . . . . . 10.00 <br /> :e Well . . . . . . . . . . . 5.00 <br /> �yyf�yti ,� Septic Tank . . . . . . . 1.0 <br /> Combination Building, Sanitary <br /> and Well . . . . . . . . 15.00 <br /> .'t a ............ 1....7.7... ... .. .... <br /> Sign n.atu.re of Owner or Agent Date Z ingS A inistrator <br /> Inspection Date/ �� .�..1..��/..... Inspector �' F 1.. . ... :.. L z <,............................... <br /> Remark�s� . .. . . . ' �. ....... ................................... <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 />