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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION ($50) <br /> *POWTS RECONNECTION W%4 `0 <br /> POWTS REVISION ($25) <br /> Application Information—Type or Print <br /> Property Owner Name '' ,,/!' Propertyy Legal Description �> <br /> CVI s H`e �"K rSA C GL S14-1114 StA/4,S�,IJEEC <br /> Property O ers Mailing Address Lot Number Block Number <br /> a3 )s-V S. w. r/wu 'k d, <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> Type of Building: (Check one) ❑ State-Owne ❑City Nearest Ro d <br /> 5 1 or 2 Family Dwelling-No.of Bedrooms: y ❑Village W� 11, r <br /> 11Public Town of its FiY mbek-D <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) 2 (J <br /> campground,festival,recreation/entenainment event etc.)] <br /> Oi/L- �SZO-62 70o <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> ❑ Non-Plumbing(Privy,Toilet,Restroom etc.) ❑ Privy—Pit Toilet ❑ Composting Toilet System <br /> 6Z POINTS Reconnection ❑ Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> ❑ POINTS Repair County#o�5� _gallons or cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State# ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> ❑ I,the undersigned,assume responsibility for the POINTS activity for which this permit is issued. <br /> ❑1,the undersigned,assume responsibility ft the installation of the non- lumbin sanitary system for which this permit is issued. <br /> Plumb r s/Owner's N me(print) PI bens/Owner's gn e: MP/MPRSW No.: Business Phone Number: <br /> t`�S oe1- r I (.tom J/F <br /> Plumber's Address(Street,City,State,Zip Code): <br /> a KT- <br /> Office Use Only: 17 1411 <br /> ❑Disapproved Permit Fee: CST No. Date Issued Issuin nt Sign re <br /> lit Approved ❑Owner Given Initial Adverse C y� '/ 1 <br /> Determination ✓U rB V <br /> Comments: <br /> 60-mr hft ru pnyjnvl so•t+{aw✓ &iw. , Tye w.s set<, cuss Can <br /> doe (v C'V46"'6t .. rr+ F-K• Yc". $rlX OF &"K AA4e &.,( 5YS'64 , /�*e- <br /> Fcwct %-r room rs as k1jtr L4%0416 4 o(a.«•aev <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised 6/7/02 <br />