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Burnett County Office of Zoning Administrator t„ -o o Z <br /> D D N ° ° <br /> APPLICATION FOR SANITARY — LAND USE — BUILDING PERMIT ° 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a o <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, m <br /> Sanitation Code, and with all other applicable County Ordinances and the laws and regu- -0 ° <br /> lations of the State of Wisconsin. a f . <br /> N V •,^ <br /> . . . . . . . . . . . . . . . . . . .S . . . . . . . . . . . . . . . <br /> Owner or Agent (please print) Contractor. . . . . . <br /> or Surveyor� .�f <br /> fDin i <br /> 30 . Svnse t . . ./qmh . :7 .4mr. . ��/s� .�v!. . . ss�oaa a ro <br /> Address Address a <br /> m <br /> has-a� . . . . . . . . . . . . . . . . . . . . <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Phone Phone <br /> hu. . mber* .er . . . . . . . . . . . . . . . . . . . . . . . . . . WellDriller. . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> � <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ddre. .ss. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . O <br /> Address A <br /> 0 0 <br /> n o <br /> Phone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Phone . . . . . . . . . . . . . . . . . . . . . . � � ° <br /> �t 0 :r <br /> o <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: ° <br /> Type of Construction No. Bathrooms . • • • • • 4 o Z °° <br /> 1. Work C9gC:u��. . . . . . . . No. Bedrooms ° <br /> m <br /> New Building �C. . . Size ft. x ft. Septic Tank Size Gals. <br /> Addition . . . . . . Height . . . . . Stories . . . . . . <br /> Sanitary . . . . . . Area . . . . . . . . . . . . . . . . . . . <br /> 7a.Absorption Field Site: <br /> Filling . . . . . . Soil Type . . . . . . . . . <br /> . . . . . . . . . o <br /> Moving . . . . . . 5. Permits Required Slope . . . . . . . . . . . . . . . . . . . . <br /> Grading . . . . . Subdivision . . . _ . . Perc. Rate . . . . . . . . . . . . . . . . . <br /> Mobile Home . . . . . . Sanitary Dry Well . . . . . . m m :M <br /> Privy . . . . . . Building , • , , , , Seepage Trench . . . . . . 0 :� <br /> Well . . . . . . Well Privy ;+ <br /> Seepage Bed <br /> Subdivision . . . . . . Other (Specify) . . . . . . o <br /> .O <br /> Conditional \� <br /> 2. Classification Land Use . . . . . . :� a <br /> Zoning Dist. o <br /> H4 6. Use (describe exactly, 1 - fam. <br /> 3. Lot Size home, motel, etc.) FOR COMMERCIAL USE :T ° <br /> ft. x ft. Plans Submitted <br /> A 3 <br /> . :p0 <br /> . . . . . . . . . . . . . . . . . . sq. ft. Plans Approved . . . . . . (r, <br /> ------------------------------------ <br /> Fig. A. Location of proposed structures and <br /> existing structures, well, sewage sys- o <br /> terns, roads, etc., should be sketched :-Is <br /> in Fig. A. Include road setback, side fv s <br /> K4-1- and back yard dimension and location 1 <br /> = and setback from all bodies of water. <br /> If property is located at a highway in- <br /> tersection, show the intersecting <br /> high- <br /> ways and the setbacks required atony <br /> them and at the intersection. <br /> �y13Trnq PERMIT FEES :o �, <br /> C FOI'% Subdivision..... $25.00 + $2.00 per lot. <br /> ^ Land Use..................0.............. $10.00 Cly <br /> Building................................... <br /> t Sanitary ..............0.......0........... 20.00 ) <br /> S Well ........................................ 10.00 � <br /> f <br /> Septic Tank 10.00 <br /> Privy ....................................... 5.00 <br /> aso' J <br /> 0 -- <br /> ,. :....................... ... ................... <br /> Signature of Owner or Agent Date Zoning Administrator <br /> InspectionDate ................................................ Inspector ................................................................................................ <br /> Remarks ............................................................................................................................................................ <br /> ................................................................................................................................................................................................ <br /> ................................................................................................................................................................................................ <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 />