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Orb en I), <br /> Application No. 40 7/ <br /> APPLICATION FOR BUILDING & SANITARY PERMIT <br /> Burnett County, Wisconsin <br /> Date 6 — 19 e7U <br /> qua Name Address a , , G <br /> Owner-Occu nt ) <br /> Gov' t . Lot No. <br /> i <br /> Phone # / 79 <br /> 97 <br /> Location G - k�t -7 �� of Sec . � T (Q N, R /� , A cre <br /> s� <br /> Lot No. f Block No. Subdivision Lot Size <br /> Contractor: <br /> [( Building construction or alteration with private sewer and water <br /> system. ~� <br /> Construction p� / <br /> New, Addition, Moved, Etc .T <br /> Use � No. Bedrooms <br /> (Family dwelling, Commercial, Etc. ) (If dwelling) <br /> ( 3 Sewage Disposal Unit . <br /> Type of installation <br /> ZSeptic Tank, Dry Well, Seepage Field, Etc . ) <br /> [ 3 Well. g ----- <br /> Driven Drilled Planned Depth <br /> CERTIFICATE <br /> I, the undersigned, hereby certify that the above statements and any <br /> attached information are true and correct to the b st of my kno ledge . <br /> Applicant <br /> Address j6,c 7247,474-eaL) <br /> Receipt <br /> Permit Issued L - E- - 7d No. Permit Denied Qj <br /> (Date) (Date/ <br /> Reason for denial <br /> Note: <br /> Submit completed application and $6 . 00 fee to: Truman Smith, <br /> Burnett County Zoning Administrator, Box 117 , Webster, Wis . 54893. <br /> In the case of sewerage disposal systems, a copy of the percolation <br /> test must be attached to this application before a permit will be <br /> issued. Do not purchase or install a septic tank, do any plumbing or <br /> start any building until a permit has been issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed <br /> herewith is found to exist . Changes in plans or specifications shall <br /> ,.,� hra mania without annroval of the Zoning Administrator. <br />