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Application No. 171 <br /> ..._._..r. <br /> APPLICATION FOR SANITARY PERMIT <br /> Burnett Ccunty, Wisconsin , <br /> Date P4 •� _1��..� <br /> Name Address Ey C-) 6 s -K r w <br /> r•r r r.r •r r it • .�•.`�.• <br /> Owner-Occupant - <br /> �u/b�c�c9- <br /> Government Lot No. . L <br /> Location: A of 34 of Sec. N R W, AcresS,�„�, <br /> t No. - IBlock No. Subdivision , Lot Size <br /> Name of person in charge of installation ,,,5 ;, ,L �• ••�r._.__ __._.,.._..-.-..---- <br /> Building construction or alteration with private sewer and water system. <br /> Construction A <br /> New, Addition, Moved, Etc. <br /> Use Na. of Bedrooms <br /> Family Dwelling, Commercial,Etc. rr if a dwell g) <br /> Sewage Disposal Unit. <br /> Type of Installation <br /> Septic Tank, Dry Well, Disposal Field, Eta. <br /> _r..t We 11. <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 best of my knowledge. <br /> Applicant <br /> Address <br /> Permit Issue d°" .Z 3 Permit No. 1 21 Receipt No. _Permit Denied <br /> Date (Date) <br /> Reason for denial - -- <br /> Signed <br /> Zoning Admininstrator <br /> Note: <br /> Submit completed application and fee to: Zoning Administrator. <br /> Do not purchase or install a septic tank, do any plumbing, or start any <br /> building, until a permit has been issued. A permit may be revoked if <br /> misrepresentation of any of the information conveyed herewith is found <br /> to exist. Changes in plans or specifications shall not be made without <br /> approval of the Zoning Administrator. <br />