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Application No. -----rZ <br /> APPLICATION FOR SANITARY PERMIT <br /> Burnett County, Wisconsin <br /> Date 140 l9 <br /> I� <br /> Name U�l��U' n Kr 1/- Address �o x 3���/ <br /> (Owner-Occupant) <br /> Government Lot No. <br /> Locatic n: ' of 14 of Sec. T N R K Acres <br /> Lot No. Block No. Subdivision Lot Size <br /> Name of person in charge of installation lam& 7^/1 <br /> 1 Building construction or alteration with private sewer and water system. <br /> Construction a ht " G�Z� <br /> ew, Addition, Moved, Etc. ) <br /> Use k-�- No. of Bedrooms <br /> Family Dwelling, Commercial, Etc. if a dwelling) <br /> 1_Xj Sewage Disposal Unit. <br /> Type of Installation <br /> Septic Tank, Dry Well, Disposal Field, Etc. <br /> { Well. <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 ' ��� l�Permit No. -..L-=•L• Receipt No. �1 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 />