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C L / <br /> Burnett County Office of Zoning Administri itor �' o <br /> APPLICATION FOR SANITARY - LAND USE - BUILDING PERMIT ^' 3 <br /> ° WTO THE ZONING ADMINISTRATOR: The undersigned hereby makes application for a Permit for the work described and 0 <br /> located as shown herein. The undersigned agrees that all work shall be done in accordance with the requirements of the n 12 <br /> Burnett County Land Use Ordinance, Sanitation Code, and with all other applicable County Ordinances and the laws and 3 <br /> regulations of the State of Wisconsin. n <br /> Joseph Gunderson A <br /> .............. <br /> ........................................................................ . . . . . . . . ............................................... <br /> OWNER (pleax print) CONTRACTOR or SURVEYOR or AGENT <br /> 10071 75th St. N. <br /> .......................................................................... .................................................................................... ....... d c <br /> i3 <br /> ADDRESS ADDRESS = ;N- 4 <br /> : <br /> Stillwater, MN 55082 i io o:m <br /> . . ................................................................................ <br /> ADDRESS ADDRESS <br /> 612-439-8743 <br /> ............................................................. . .............. —........................................................ ....... <br /> PHONE PHON.........E <br /> Donald Daniels C <br /> 1 :(D <br /> PLUMBER............................................................................ .WELL DRILLE..R.............................................. <br /> ............. <br /> .... (D <br /> Box..W......Siren.,...Wi.....5�7.2.............................. <br /> ADDRESS ............................................................... . . ..... .... .... ...... ....... o <br /> ADDRESS <br /> C) ::I <br /> .....'7.1.5- ?3. 9=553.3.......................................................... 5 ` <br /> ' <br /> PHONE PHONE Z N <br /> DESCRIPTION 4. Sanitary Facilities: °_ o 0 <br /> 1. Work: No. Bathrooms .. ..1.... <br /> 2. New Building Details <br /> New Building „ ,,,,,,,, Type of Construction: No. Bedrooms ...... ;O <br /> Septic Tank Size Gals. 'w <br /> Addition .................................................... .... < <br /> Sanitary X..... Size .............. ft. x .............. ft. .. ....... <br /> .... <br /> Filling/Grading .......... Height............. Stories ............... 4a. Absorption Field Site: <br /> Moving .......... Area ........................................... Soil Type ............................ ....... .o <br /> Slope .................................. . <br /> MODIIa Home .......... ”"" v <br /> Priv Perc. Rate ........................... d <br /> Privy 3. Use (describe exactly -family " 0 o <br /> Well Dry Well......... home,garage, motel,etc.) """Trench 'z <br /> Seepage Subdivision 9 """ <br /> Camping Unit .......... o cr Q- <br /> .................................................... <br /> r <br /> .. ........ .... ........................ .� 'Y <br /> Ni- <br /> ........ .......... .... ..... .... ... ........... Privy ......Seepage Bed <br /> x.... <br /> ---------------------------------------------------------------------- <br /> Location of proposed structures and existing structures, well, sewage systems, roads, etc., should be sketched in Fi . A. <br /> Include road setback,side and back yard dimension and location and setback from all bodies of water. If property is loca ed at _--C� 9 �. ' <br /> a highway intersection, show the intersecting highways and the setbacks required along them and at the intersec ion. <br /> CLEARLY LABEL EXISTING STRUCTURES AND PROPOSED STRUCTURES AND ADDITIONS. 'G- <br /> ------------------------------------------------------------------- — <br /> 5. Lot Size: Fig. A. 6. Location: i o <br /> ................ ft. x .............. ft. — ............................... sq.ft. ...................................................................... ........ <br /> m n <br /> N y O <br /> o a <br /> SEE STATE APPROVED PLAN o r <br /> 0 0 <br /> J <br /> 1 <br /> m <br /> Z <br /> 0 <br /> C M <br /> IV °M <br /> CJ pM <br /> b m <br /> 7b <br /> S <br /> N c74 <br /> -o N N n cm co -0 <br /> mo <br /> 0 o' < 00n - - m <br /> m Nn� -' nm nn A <br /> 0 05i iu cy > > ; <br /> o 2 o m m <br /> Z—o � D � <br /> n : y <br /> o c' m <br /> o <br /> 7 - <br /> � ................. ....... ..�../'J... C! <br /> O <br /> c_ <br /> n : m <br /> Si A�deror Agent Date C <br /> o : <br /> Remarks " y <br /> �V�9�qI� �/ ^ o : 8 <br /> Inspection Date ..\.... ...... 4V.W.... ..:.......�.XMf.!lA.. ....... ..... N D7 N N m <br /> ....................................... g v' <nrnoofnm <br /> Zonin Administr r 8 8 8 8 8 8 w <br /> NOTE: A preliminary site inspection must be made and site approval granted on all structures involving sanitary facilities before construction <br /> can begin. In the case of sewerage disposal systems,a copy of the percolation test must be attached to this app ication before a permit will <br /> be issued. Do not purchase or install a septic tank, do any plumbing or start any building until a permit has been issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed herewith is found to exist. Changes in plans or specifications shall not be <br /> made without approval of the Zoning Administrator. <br /> SEWER SYSTEM SHALL NOT BE COVERED UNTIL INSPECTED BY THIS OFFICE AND APPROVED. <br />