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a Application No.� <br />APPLICATION FOP BUILDING & ,SANITARY PERMIT <br />Burnett County, Wisconsin <br />nate - 19� <br />Name Address <br />Owner -Occupant <br />Gov't Lot No. <br />Location:�� % of ZZf of Sec. `T , T N, R W. Acres <br />Lot No. Block No. Subdivision Lot Size <br />Name of person in charne of installation <br />Building construction or alteration with private sewer and water <br />11 system. <br />Construction <br />New, Addition, Moved, Etc. <br />Use No. Bedrooms <br />Family dwelling, Commercial, Etc. (If dwelling <br />ewage Disposal Unit. <br />Type of Installation <br />(Septic Tank, Dry Well, Seepage Field, Etc. <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 />Recei t <br />Permit Issued 2j7- /1_1,f `� No. Y7'7'� Permit Denied <br />(Date) Date <br />Reason for denial <br />Note: <br />Submit completed application and $6.00 fee to: Fred 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 />