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Burnett County Office of Zoning Administrator <br /> CD CD 6 z <br /> m 0 o 0 <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT °. 3 C <br /> h <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a -I _ o .SIL., <br /> Permit for the work described and located as shown herein. The undersigned agrees that all _ 1/41 <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, 7- C kii <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- ° <br /> lations of the State of.Wisconsin. --1. O <br /> a <br /> /n� � -. �� <br /> I, ICJ 0 rld / 1 `= <br /> wner or Agent (please print) Contractor or Surveyor y v <br /> c O <br /> (�., . Ls rr wtSc, 7 <br /> Address Address o T <br /> d • <br /> ' \ <br /> Phone Phone <br /> b <br /> Plumber Well Driller <br /> t v o <br /> Address Address m O <br /> C) 0 <br /> < <br /> ;IS'a xi 5 .-.7 <br /> Phone Phone CD o <br /> CD o <br /> D ESC R I PT 10 N 4. Building Details 7. Sanitary Facilities: <br /> Type o Con ruction - No. Bathrooms o z °° <br /> 1. Work .Tf 0' 'T 1 .� KO-F(1)0 No. Bedrooms 1 ° <br /> New Building Size ft. x ft. Septic Tank Size Gals. . . ., ♦AT <br /> Addition Height Stories .IS.'�t �"'"'\��� <br /> Sanitary `-� Area 7a.Absorption Field Site: � <br /> Filling Soil Type Slope /�mQ o <br /> .» <br /> Moving 5. Permits Required . <br /> Grading Subdivision / Perc. Rate <br /> Mobile Home Sanitary •./ Dry Well CD CD <br /> Privy Building Seepage TrenchEA fa - ill <br /> Well . . Well , ,1r.e..-- Privy �/ -a <br /> Subdivision Other (Specify) Seepage Bed i k ! o <br /> Conditional O N cn <br /> c m <br /> 2. Classification Land Use a a C) <br /> • <br /> Zoning Dist. •-. g <br /> 6. Use (describe exactly, fam. <br /> 3. Lot Size home, motel,etc.) FOR COMMERCIAL USE ° <br /> ft. x ft. Plans Submitted <br /> . . . Cr'!-?4:... . . . sq ft. Plans Approved <br /> Fig. A. /0 Location of proposed structures and <br /> existing structures, well, sewage sys- 0 <br /> — <br /> (.41 T L.1 N.''‘ tems, roads, etc., should be sketched x, <br /> in Fig. A. Include road setback, side 1 <br /> and back yard dimension and location -.13..) :0-. <br /> and setback from all bodies of water. <br /> tb - If property is located at a highway in- <br /> A �.l <br /> ;T1'�tersection, show the intersecting high- (`; <br /> V ways and the setbacks required along ` <br /> -I �Cit <br /> �1- them and at the intersection. <br /> PERMIT FEES <br /> E----Q` ) Subdivision $15.00 fD <br /> 0-g'(� Land Use 1.00 <br /> Building 5.00 ii..., <br /> Sanitary 10.00 <br /> Well 5.00 C' <br /> Septic Tank Poo k. <br /> Combination Building, Sanitary <br /> and Well 15.00 <br /> Privy 5.00 <br /> R , <br /> --‘-,' '.,z,,e4, -, x <br /> Signat re of Owner or Agent Date Zon Administrator <br /> _ q'� T a <br /> Inspection Date ~/ ( 7 ( Inspector <br /> Remarks ( /r... 1.... ' ' `(2 I <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 />