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1 CortiJ� <br /> Burnett'County Office of Zoning Administrator � a o y z <br /> APPLICATION FOR SANITARY— LAND L;SE BUILDING PERMIT a 3 <br /> o <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a <br /> Permit for.thework 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, x 4` <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and reign- v <br /> lotionsTTo--f the State. of Wisco in. CT� <br /> . . . . n. : 7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . ? E Ef <br /> P G <br /> U'wner or Ayentyptease print) Contractor or Surveyor ?ht <br /> a <br /> Address Address '_� <br /> c <br /> kti <br /> m I <br /> . . . . . <br /> Phone Phone n . . . . . . . . . . . . . . . . . . . . . . . . . . . . i { J <br /> - Phone <br /> Plumber . . . . . . . . . . . Well Driller. . . . . . ... . . . . . . . . . . . . . . . . . . . . <br /> Y1 <br /> . Yn❑❑ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Address �0 ll+�'� 'ri"ta5 TS Address <br /> . . . . . . . . . . . . . . . . . . p <br /> Phone- Phone <br /> t a <br /> 'DESCRIPTION 4. Building Details T Sanitary Facilities <br /> _ Type�ons�yction No. Bathrooms . . L . z z o <br /> 1. Work ` !'.t, 1/ Dishwasher <br /> New Building . . . Size a.�, ft. x .7.. . . ft. Garbage Grinder . . . . . . :�;\ <br /> Addition Height . . . . . Stories . . . . . . Amore. Laundry <br /> - Sanitary . . . . . Area . . . . .. . . . . . . . . . . . . . -No. Bedrooms . . .P.-' 0 <br /> 'Alterations . . . . . . Waste Disposal System -. . . . . . �: ° <br /> Moving _ . . . . . 5. Permits Required Septic Tank Size Gals. /�?J. . V <br /> Wrecking . . . . . . Subdivision Absarptian Field Site ti <br /> Mobile Home Sanitary Soil Type „ _ . . . . . . . <br /> Privy Building Slot, <br /> Well Well +. . . .. . Peres Rate . .gin 1 . . .e <br /> Subdivision . . . . . . Other fSpecify) . . . . . . .Dry Well . . . . . . o ' <br /> Conditional . . . . . . Seepage Trench . . . . . . [ f u' <br /> 2. Classification // Land . . . . . . Privy C <br /> P <br /> i Zoning Dist Seepage Be,] C t1A �.y o <br /> 6. Use (describe exactl i -fam. <br /> 3. Lo[Size home, motel,etc.) FOR COMMERCIAL USE <br /> ft. x ft Plans Submitted Q) <br /> . . .�'�. .Q.!J . . . sq. ft. Plans Approved . . . . . . <br /> __________ <br /> ____ ________________________ <br /> Fig. A. ��✓t. <br /> f Location of proposed structures and <br /> existing structures, well, sewage sys3. o <br /> lems, roads, etc., should be sketched ` s <br /> in Fig. A. Include road setback, side f1j) <br /> and back yard dimension and location <br /> and setback from all bodies of water. <br /> If property is located ata highway in <br /> ,3otersection, show the intersecting high <br /> 0c a Je `7 ways and the setbacks required along <br /> them and at the intersection. - :k <br /> PERMIT FEES _ O ✓ 'I <br /> _ �S� /J Subdivision $15.00 ar , <br /> ' 00 Land Use . . . . . . . . 1.00 <br /> Building 5.00 :L <br /> (� Sanitary 10.00 <br /> Well . . . . . . . . . 5.00 C <br /> t7 Septic Tank _ 00 <br /> Combination Building, Sanitary <br /> and Well 0 <br /> .............. ..... a��uLS................................ ...6- 7r.... /f Z +......... <br /> l� X0,:.....77.. <br /> ... .. L"J� ...!/a....... .. ... � .. Administrator <br /> .. <br /> Inspection Datere of wneK��Agent Victor ate L / Z/ on �` <br /> Remarks <br /> ........... ...................................................................................................................................................................... <br /> ............................................................................................................................................................. <br /> .....................:............. <br /> NOTE: .A preliminary site inspection must be made and site approval granted on all structures inv O lving 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- I <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 />