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^ Burnett County ^' w Office of Zoning Administrator V ly 1 0 <br /> y <br /> "z- o <br /> APPLICATION FOR SANITARY — LAND USE_+ BUILDING PERMIT = 3 <br /> TO THE-ZONING ADMINISTRATOR: The undersigned hereby makes application for a <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 ra,Pi,ements of the County Zoning Ordinance, s a �` <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- c, V. <br /> lations of the State of Wisconsin. <br /> c \ : O <br /> C!f/or� rs c WZZ— . . . . . . . . . 3 - <br /> Own/err or Agent (Please print) <br /> /CorContractor or Surveyor •^ :� <br /> / r c <br /> . . . . . . . . . . . . . . . .'. . . . . . . . . . . . . . . . . . . . c <br /> Address Address 'a <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . :. . . . . . . . . . . . . . ^ <br /> Phone <br /> Phone <br /> !2. . . . 1 V <br /> Plumber Well Duller <br /> S <br /> 1 <br /> . / �. . . . .SH�«. . . . . <br /> . . . . . . . �/�k.'d�. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Address AddressJ2 41, <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Phone Phone N <br /> 0 <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: v' <br /> Type of Construction No. Bathrooms <br /> 1. Work . . . . . /�. . . . . . . . . . . No. Bedrooms <br /> New Building . .x. . . Size 4r. it. fl. Septic Tank Size Gals. IQQP. <br /> Addition Height q �Stories . ./. . . . . . . <br /> N . . <br /> Sanitary . . . . . . . Area . . . . (. . . . . . . . . . ]..Absorption Field Site: dbL i / <br /> Filling . . . . . . Soil Type �. <br /> Moving . . . . . . 5. Permits Required Slope . . . . . . . . . . . . . . i <br /> Grading . . . . . . Subdivision Pere Rate . . . . . . . <br /> . . . . j. .. . . . . . A A <br /> Mobile Home . . . . . Sanitary k Dry Well . . . . . . m <br /> Privy . . Building 1< , . Seepage Trench . . . . . . <br /> Well . .K. . Well . . :. Privy <br /> . . . . . . :\ <br /> Subdivision . . . Other (Specify) . . . . . . Seepage Bed . . .V. . o <br /> Conditional . . . . . . m n <br /> 1 c <br /> 2. Classification �i//�_ Land Use . . . . . . Z. <br /> Zoning Dist. J / . .v.. a <br /> 6. Use (describe exactly, 1 tam. Z. <br /> 3. Lot Size home,motel,etc. FOR COMMERCIAL USE - i <br /> yo A •`p <br /> . . . . . . . . . ft. x ft. }� Plans Submitted <br /> . . . . . . . . . . . . . . . . . . sq. ft. Plans Approved . . . . . . .– <br /> ----------------------------------------------------------- <br /> Fig. A <br /> Location of proposed structures and <br /> existing structures, well, sewage Sys of <br /> tems, roads, etc., should be sketched F <br /> in Fig. A. Include road setback, side ! `? <br /> and back yard dimension and location Q <br /> \ and setback from all bodies of water. i 3: <br /> If property is located at a highway in <br /> — \ tersection, show the intersecting high. <br /> ways and the setbacks required along <br /> I / 1 them and at the intersection. ; <br /> i <br /> PERMIT FEES \ v <br /> ( Subdivision 515.00 C <br /> Land Use . . . . . . . . . . . . 1.00 : <br /> Building . . . . . . . . . . . 5.00 <br /> Sanitary . . . . . . 10.00 <br /> Well 5.00 - t ( <br /> Septic Tank . . . . . <br /> Combination Building, Sanitary , �t <br /> 1 and Well 570 <br /> t <br /> \ Privy . . . . . . . . . . . . <br /> S' nature of Owner or Agent � �� ���6�nis <br /> 9 /�5 g q' Date Zo g�[,p t rotor I <br /> Inspection Date C.`'. ..:�.._ ._7.L............ Inspector <br /> Remarks <br /> ................................................................................I.,............................................................................................. <br /> ......:.. ... <br /> ............................................................................................................................................................................................\s <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`ttached`I <br /> this application before a permit will be issued. Do not purchase or install a septic.tank, do any plumbing or start any built <br /> ing until a permit has been issued. A permit may be revoked it misrepresentation of any of the in <br /> tion conveyed hen <br /> with is found to exist. Changes in plans or specifications shall not be made without ap`prova Pof the Zoning Administrator <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED 8,Y THI;`FFICE AND APPROVED. <br />