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10/29/2006 11:41 3492166 B C ZONING PAGE 01 <br /> BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN,WISCONSIN 54872 <br /> 715-349-2138 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION(5150) <br /> POWTS RECONNECTIO?tj� <br /> POWTS REVISION($50) <br /> Application Information—Type or Print <br /> Property Name .11I� Property 1xim rmseripeon <br /> GL 02 1/4 Ila,S.JT-?7N R 1 w <br /> ProWyOwmi's Mailing Address Lot Number Block Number <br /> 3Yaj1% Are, S <br /> City,Scale Zip Code Phone Number Subdivision Name or CSM Number <br /> PL /�/j ISTYAC 37y-375 <br /> type of Building: (Check one)O State-Owner p City a a <br /> !4, llor2Family Dwelling-No.ofBedroom; 0 Village ? <br /> ❑ Public Town of ( ire Number 1�S <br /> Public Building/Land Use: (gxplam the U-1purpose for this permit,(i.c., Parcel Tax Number(n) <br /> ==ground,fcatival,rwraanoo/mtcrtainment e,ut ete.)I <br /> 034- )FR,2-91- WO <br /> Type of Permit: Type of Non-Plumbing Device/System/roilet/Unit: <br /> ❑ Non-Plumbing(Privy,Toiler,Reatroom etc.) ❑ Privy-pit Toilet ❑ Commetin Toilets <br /> POW-1 R000mledlon p pri g Y <br /> PO=TS Repair Cotmty# Qom` t'Y-Vault Toile[(Vault size: ❑ Inc negating Toilet Device <br /> ❑ Revision State# 10 al, ��0 Pill or _cubic yards) ❑ Portable Restroom Unit <br /> Responsibility Statement: (Check one or both as appropriate.) <br /> ❑1,the undersigned,assume responsibility for the PO=TS activity for which this permit is issued. <br /> ❑ the undersi ed,assume r9sPonsibillitv for the installation of the non- lumbin sani a em for which this it is issued. <br /> Piumtwr's/Orvriar's Name(print) Plumber' wnn's Sign MP/MPRSW No.: f Business Phone Number: <br /> z77� `�� <br /> Plumbers Address(Street City,Since,Zip Codc): <br /> Office Use Only: <br /> ❑OtsaDPro�d Pemdt Pee: CST No. date Iso Iss t Si <br /> Approved O Owner Given hritid Adverse 'I <br /> lknrrirtation '� NGv �v , <br /> Comments: <br /> Conditions of Approval/Reasom for Disapproval: <br /> Revised 6!7/02 <br />