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Ur L WrJ' i <br /> Burnett County Office of Zoning Administrator N73 o -IZ <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ° 3 co <br /> c . <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a -I ' o _t <br /> Permit for the work described and located as shown herein. The undersigned agrees that all E. <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- - <br /> lations of the State of Wisconsin. ° 0 <br /> J fD <br /> L To ,,C CD <br /> Owr er or Agent (please print) Contractor or Surveyor c <br /> T1/4; <br /> L <br /> Address Address d 'O <br /> CD <br /> } ...\$k --N ..1 r-- <br /> Phone <br /> Phone "l <br /> k . tic iS <br /> Pluber Well Driller <br /> m 0 <br /> 0 Z.- <br /> Address Address Pp- C) ;'ti <br /> .... <br /> -« <br /> Phone Phone 0 0 <br /> CD o r. <br /> D ESC R I PT 10 N 4. Building Details 7. Sanitary Facilities: -o <br /> Type of ConstruceLip n No. Bathrooms i o z °6 (� <br /> 1. Work --' x/ 4' / h No. Bedrooms '"• • ° �+--- <br /> New Building Size ft. x ft. Septic Tank Size Gals. .- <br /> Addition Height Stories ; 11 <br /> 7a.Absorption Field Site: F' <br /> �/� <br /> Sanitary Area S A <br /> V C <br /> Filling Soil Type ' <br /> Moving 5. Permits Required <br /> Slope h <br /> Grading Subdivision Perc. Rate ! f <br /> Mobile Home Sanitary 4.!! Dry Well f . X7 CD CD C <br /> Privy Building Seepage Trench CD <br /> C <br /> Well Well Privy <br /> Subdivision Other (Specify) Seepage Bed c <br /> '1 N N <br /> Conditional {�—.� CD <br /> 2. Classification Land Use a- C <br /> Zoning Dist. <br /> • <br /> 6. Use (describe exactly all, ^� o, o <br /> 3. Lot Size t/ home, motel,etc.) FOR COMMERCIAL USE IC I , 'cu <br /> Q.0 �' ft x 7 a 0 ft. Plans Submitted <br /> sq. ft. Plans Approved �` <br /> JJ <br /> Fig. A. Location of proposed structures and ! n <br /> / existing structures, well, sewage sys o <br /> 1 ` , iv'��5W��1 terns, roads, etc., should be sketched D <br /> 7 Y /�\ in Fig. A. Include road setback, side <br /> '/ and back yard dimension and location L.2 16. <br /> and setback from all bodies of water. <br /> —ILA/s 1►„ If property is located at a highway in- <br /> tersection, show the intersecting high- <br /> • 7' L � �� ways and the setbacks required along <br /> them and at the intersection. <br /> Co 0In0tS <br /> C <br /> PERMIT FEES <br /> 1'4 (i— Subdivision $1 $ `D <br /> Land Use /41.00 <br /> �"�i1� Building /0 .44+9' <br /> Sanitary 49-99 'tT <br /> n - ." Well /O '�-- <br /> �J Septic Tank 10.00 <br /> Combination Building, Sanitary <br /> and Well 1."QS" <br /> Privy 5.00 <br /> /2*/ <br /> Si9 natur of Owner or Agent / Zo 1(/ gd ;nistrator <br /> 9 <br /> 7. <br /> Inspection Date ( -�g / Inspector ....�t' r .. -1 <br /> Remarks Lr'.. C 'h <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 he made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />