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1 <br /> Burnett County Office of Zoning Administrator <br /> APPLICATION FOR SANITARY — LAND USE=— BUILDING PERMIT 3 <br /> TO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a u = I o <br /> Permit for the work described and located as shown herein. The undersigned agrees that all x iw <br /> work shall be done in accordance with the requirements of the County Zoning Ordinance, °� '!•C i�. <br /> Sanitation Code, and with all other.applicable..County Ordinances and the laws and reg, � c q I <br /> "`••'lations of the State of Wisconsin. �p <br /> �wner oLA IN. <br /> Agent (please printf Contractor or Surveyor <br /> l \. <br /> IL <br /> /✓<t.. �.gin/ . . . _ . . . . .': . . . . : . _ . . . <br /> Ar ss - Address <br /> /u/i�NER�ci-i5j ihiiNiy, ^aayyi n <br /> j. ri":i.•i .:i. If 70 . . . . . . . . . . . . . . . . . . . . . t \[T <br /> Phone Phone <br /> 4—, _ . _ . . . . _ . . . _ . . . <br /> Plumber la Well Driller ( [ t <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Address _ Address <br /> a ' <br /> Phone Phone O Tzx%o9 �n <br /> o � <br /> DESCRIPTION 4. Building Details 7. Sanitary Facilities: o ti <br /> Type of Construction No. Bathrooms o z yo <br /> 1. Work . :. .C"HC ktv. . . . . . . . . . . .. No. Bedrooms <br /> New Building . . ]S. . Size Zi'c f.. it, x COl . , ft. Septic Tank Size Gals. <br /> Addition . . Height .(.%: Stories .(. . . . <br /> Sanitary . 4. t� Area . .13 1 .SS. jr; 7a.Absorption Field Site: <br /> Filling . . . . . . Soil Type . . . . . . . . . . . . . . <br /> Moving . . . . . . 5. Permits Required Slope <br /> Grading S,bdIVI510n Pec. Rate . . . . . . " T � <br /> ;Oi/. <br /> VI <br /> Mobile Home . . . . .. Sanitary ice✓ Dry Well . . . . . . A <br /> Privy . . . . . . Building .4, / Seepage Trench . . . . . . or of <br /> Well . . (-� Well _ ,1--,/ Privy, �)) r . . <br /> Subdivision . . . . . . Other (Specify) . . . _ . Seepage Be,] Y.X. )D o �./� (/l <br /> Conditional 1 ?S t^ so <br /> 2. Classification n n Land Use <br /> Zoning Dist. t = < <br /> 6. Use (describe exactly, 1 -fang. [n <br /> 3 Lot Size •yn Ge.zc7 home, motel,era.) FOR COMMERCIAL USE :c <br /> . . . . . . . . . ft.x . . . . . . . . ft. Plans Submitted <br /> Ple i5 Approved <br /> 1. - . .. . . . . .. . . . . . . . . . s ftp- ...r_.._-;t"=. :. a-'—. . . --•+-ti. . <br /> __ Gnu <br /> -, Fig.A. Location of proposed structures and S �I <br /> J� existing structures, well, sewage-sys- <br /> L4 terns, roads, etc., should be sketched <br /> in Fig. A. Include road setback, side !� <br /> and back yard dimension and location <br /> C3 and setback from all bodies of water. e \ <br /> Sts If property is located ata highway in- 1*�ikJJ <br /> 1 tersection, show the intersecting high <br /> 1 ways and the setbacks required along, :;y 1 <br /> �. r_��them and at the intersection. ; l . <br /> a t to t PERMIT FEES inin <br /> Tf v• 1� r Subdivision . . . . . . . S15.00 <br /> Land Use . . . . . . . . . . . 1.00 <br /> Building 5.00 <br /> � i Sanitary 10.00 ,.A <br /> Well 5,00 <br /> Septic Tank (*0 <br /> s Com binabgn Building, Sanitary <br /> < and Well 5,00 <br /> Privy . . . . . . . . . . . 0 1 _i <br /> Sg ature of Owner or Ayent � Date ilmstre to 'Inspection Date .� J. 7� Inspector � mss.S�ol7. �Ynod'� <br /> ��(✓-Ga' . ..- 't �/ / / q.� .. ._ ... <br /> Remarks �// Gl -�'-/- .....�GO..?C/ (.:....1/..14r. <br /> ........:............. <br /> y <br /> NOTE: A preliminary site inspection must be made and site approval granted on:all structures involving sanitary faciliti i.7 <br /> before construction can begin. In the case of sewerage disposal systems, a copy of the percolation test must be at:ached'I <br /> this application before a permit will be issued. Do not purchase or install a septic tank, do any,plu m Bing or start any buil <br /> inguntil a permirlhas been issued. A permit may he revoked if misrepresentation of'any of the information conveyed h¢i <br /> with is found to exist. Changes in plans or specifications strait not be made with„Yapproyal of the Zoning Atlminietra Af <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BYJTHIS OFFICE AND 'APPROVED. <br />