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(1 l <br /> Application No.J:2. e._ <br /> , 1 -I ��' APPLICATION FOR BUILDING & SANITARY PERMIT <br /> Burnett County, Wisconsin <br /> Date //-10 19 PO <br /> Name i¢r e Cf. 5 aiy .aicaLS,c, <br /> Address <br /> ,Owner-•ccupant) <br /> Phone # <br /> Gov' t . Lot No. <br /> Location: 4A0 ofE% of Sec . ,A.. .. ' <br /> , T3Y N, R / W, Acres <br /> Y/ <br /> Lot No. Block o. Subdivision Lot Size <br /> Contractor: 00 n/ a_At! � <br /> [ ir Building construction oralteration with private sewer and water <br /> system. ____� .__ _._ _.._ <br /> ��Construction //2? d� <br /> (New, Addition, Moved, Etc . <br /> Use 1 )1 No. Bedrooms <br /> (Famil awe lin: , Commercial, Etc. ) (If dwelling) <br /> [Sewage Disposal Unit . <br /> Type of installationfL LA( 4-- O' ' 0 <br /> sL 117 - <br /> ept c Tank, Dry Well, See. ge eld, Etc . ) <br /> Cell. <br /> Driven Drilled Planned Depth 7a 4pp#Q0 y _ <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 ,4e/ -t� � - J <br /> Address <br /> h Receipt <br /> 0 / 0 <br /> Permit Issued ',�,� No. Permit Denied <br /> (rate) (Datef `- <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 /> _ slued. Do not purchase or install a septic tank, do any plumbing or <br /> st,rt any building until a permit has been issued. A permit may be <br /> revoked if misrepresentation of any of the information conveyed <br /> .r:rewith is found to exist . Changes in plans or specifications shall <br /> not be made without anoroval of the Zoning._ Administrator. <br />