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Burnett County Office of Zoning Administrator N CjCz <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT °. 3 c <br /> THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a ,— <br /> - <br /> TO o NIIIIr <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 1 <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- -o ° o <br /> lations of the State of Wisconsi q1 �. O <br /> �( � 3 t <br /> 0 1r or Agent (please print) Contractor or Surveyor <br /> N <br /> N <br /> / r IV r- CD <br /> 3 7 l. r J ��Q � S SS' yoL( a v 7 <br /> Address Address a <br /> a) tt f.." <br /> c. <br /> C / a ' ? fa'-' `/ 73y ..7-- <br /> Phone Phone <br /> 61-7" <br /> Plumber Well Driller ...-.) <br /> rt o 4 <br /> Address Address o <br /> f0 < A, <br /> NiP6bne Phone o <br /> 1 �lc DESCRIPTION 4. Building Details 7. Sanitary Facilities: / ° ° <br /> Type ofiConstrUctt on No. Bathrooms o z -°a <br /> 1. Work l t• 4! 4 -,4., r" No. Bedrooms • •c�- • ° co <br /> New Building Size / ) ft. x S ft. Septic Tank Size Gals. —3- .Z <br /> Addition . . Height Stories . . . .•. . �. (7 J.A, TT) <br /> 7a.Absorption Field Site: <br /> Sanitary Area G o <br /> p <br /> Soil Type <br /> Filling ° <br /> Moving 5. Permits Required Slope <br /> Grading _ Subdivision Perc. Rate <br /> Mobile Home (---`- Sanitary L. Dry Well CD � ¢ <br /> Privy Building Seepage Trench •-EA VI t '� <br /> ll Well Privy �/ t 1 <br /> SuWebdivision Other (Specify) Seepage Bed � �°�7 o x� '4,,,s <br /> Conditional cn <br /> cn <br /> 2. Classification R -1....,. Land Use . . _ ' a �_«Zoning Dist. <. ° <br /> 6. Use (describe exactl , 1 fam. tit y' <br /> 3. Lot Size } home, motel,etc.) FOR COMMERCIAL USE ° <br /> . 3(9. . ft. x ft. Plans Submitted G° <br /> / CaL-r-'4- sq ft. Plans Approved <br /> Rh <br /> h <br /> mciI1;DK // � 27 , ) Location of proposed structures and <br /> o <br /> !�� p <br /> / �/ ICJ existing structures, well, sewage sys- <br /> To- -14- <br /> A tems, roads, etc., should be sketched ° <br /> 1� in Fig. A. Include road setback, side ) - <br /> and back yard dimension and location 0 I -5 <br /> 4v r and setback from all bodies of water. <br /> 1 If property is located at a highway in- <br /> tersection, show the intersecting high- --- <br /> �� ways and the setbacks required along )3 <br /> them and at the intersection. o f <br /> PERMIT FEES r- ; <br /> Subdivision $15.00 5N.N- CD <br /> Land Use 1.00 tt I <br /> `rya' Building 5.00 <br /> lC Sanitary 10.0 4 <br /> �_ /�0, Well 5.0 v� :( <br /> Mir �� ) , <br /> S� Septic Tank fQ.00 <br /> ) Combination Building, Sanitary <br /> and Well 15.00 i <br /> J-f (' -� Privy 5.00 <br /> „t„,,,,,,....p._ 0 r),vi ..,,,,,=,_ LI--/O -7g h - /(1W <br /> rSignature f Owner or Agent Date ZZon g Ad st a <br /> ~7 fig J .� 4„ <br /> Inspection Date Vl 0/...i�.I..81 Inspector ... .............. ...0 .,. `' 41. <br /> Remark R! <br /> c.:) ./ ..- -- ,. c___,D,A____, <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilit <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be attached <br /> this application before a permit will be issued. Do not purchase or install a septic tank, do any plumbing or start any bui <br /> ing until a permit has been issued. A permit may be revoked if misrepresentation of any of the information conveyed he <br /> with is found to exist. Changes in plans or specifications shall not he made without approval of the Zoning Administrat <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />