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Burnett County Office of Zoning Administrator N/- �--i (:"-- <br /> CD CDm o 0 <br /> ' APPLICATION FOR SANITARY — LAND*OSE- 0— BUILDING PERMIT ° 3 CD <br /> * • <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a -1 '' o <br /> Permit for the work described and located as shown herein. The undersigned agrees that all y '5..\ t r <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, C .1V <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- -a o <br /> lations of the State of Wisconsin. 3 a 4 OA <br /> IJ P 1' A u ...0, P'►c m <br /> Owner or Agent (please print) Contractor or Surveyor H <br /> i .,-i-- ‘ c NI - <br /> lO cS R r DISC- CD <br /> 0- <br /> t. \ 7 <br /> Address Address a v .{ <br /> `D 3 <br /> NI <br /> Phone Phone <br /> : O-p. rci.1.). . . . . . . . . . . . . . . . icnif- be-CO.)1k_, .)\ <br /> Plumber • • • • • Well Driller e I r ' <br /> c.t-t- 5 . <br /> 1 <br /> Address Address U 0 C� , 0 0 Q. <br /> �rsrn c ' � o <br /> Phone Phone / <br /> _ 0/3--03 (D _ I— <br /> o <br /> cD 0 <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: / -° <br /> Type f Constr ion No. Bathrooms ? z z o <br /> 1. Work r - cr (tT r" No. Bedrooms 3. . • ° CD <br /> New Building Size . .1 .( ft. x 70 ft. Septic Tank Size Gals.4-------- . ``� ' <br /> Addition Height Stories I.a.e <br /> Sanitary C Area 7a.Absorption Field Site: v'` I— : <br /> Filling Soil Type o <br /> Moving 5. Permits Required Slope ° <br /> Grading / Subdivision Perc. Rate Q <br /> Mobile Home C 1. Sanitary 4_.„---- Dry Well CD CD <br /> CD CD <br /> Privy j Building . ..ow Seepage Trench <br /> Well (/ Well — Privy T�.3K% • <br /> a�� �t' fa <br /> Other (Specify) Seepage Bed ' o N. <br /> Conditional o C w' <br /> 2. Classification /] , Land Use I h <br /> Zoning Dist. L(/ a o <br /> 6. Use (describe exactly, 1 -fa H" <br /> 3. Lot Size home, motel,etc.) FOR COMMERCIAL USE 0 <br /> / l ft. Plans Submitted 0.—__,. . . !. -d�.0-!r!?S9'.v-.—sq ft. Plans Approved 7' <br /> Fig. A. Location of proposed structures and <br /> existing structures, well, sewage sys- o <br /> ® -A \ C tems, roads, etc., should be sketched � c <br /> `" in Fig. A. Include road setback, side '\) <br /> and back yard dimension and location JJ -a <br /> 1� and setback from all bodies of water. <br /> I� ' -�xr�ra If property is located at a highway in <br /> d �'�(7 is)" tersection, show the intersecting high- Ng <br /> tr ways and the setbacks required along <br /> ; )'' r them and at the intersection. + <br /> .1--.1-- r'y 1 l.r 0a PERMIT FEES — D <br /> \\ I <br /> Subdivision $15.00 ) `D <br /> co <br /> �j Land Use 1.00 • <br /> Building 5.00 • <br /> :� <br /> Sanitary 10.00 ?6� <br /> , ' • ,S l ci C Well . 0' �. <br /> Septic Tank 0 <br /> t. <br /> �^ L'. <br /> Combination Building, Sanitary <br /> and Well 15.00 <br /> [ / )( 3/G Privy 5.00 <br /> .1/ 74,,41' 06:111/../(jA <br /> Signate of Owner or Agent r' ate.. ing dmini trator 4/ <br /> Inspection Date �,, Inspector . . ... . .... <br /> Remarks ..6 // Z'U.... <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 />