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Application No. <br /> +� APPLICATION FOP BUILDING & SANITARY PERMIT <br /> Burnett County, Wisconsin <br /> ?.rate r 1911 <br /> Name C Address <br /> Owner-Occupant <br /> Gov't Lot No. <br /> �!x3 <br /> Location: % of �'4 of Sec . T {. N, P . -,. tit, Acres <br /> Lot No. Block No. Subdivision Lot Size <br /> Name of person in charge of installation <br /> Building construction or alteration with private sewer and water <br /> system. <br /> Construction ' <br /> New, Addition, Moved, Etc . <br /> Use No. Bedrooms <br /> Family dwelling, Commercial, tc . (If dwelling <br /> ewa a Disposal Unit. <br /> LLJ Type of Installation <br /> (Septic Tank, Dry Well, Seepage F eld, Etc . <br /> I� Well. <br /> w <br /> Y 7- <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 /> Receipt <br /> Permit Issued �Y /4� /9�9 No. -57'�Z Permit Denied <br /> Date (Date) <br /> Reason for denial <br /> Note: <br /> Submit completed application and $6.00 fee to: Ered Evert, Zoning <br /> Administrator, Webster, Wisconsin 54893 . Do not purchase or install <br /> a septic tank, do any plumbing or start any building until a permit <br /> has been issued. A permit may be revoked if misrepresentation of any <br /> of the information conveyed herewith is found to exist . Changes in <br /> plans or specifications shall not be made without approval of the <br /> Zoning Administrator. <br />