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v Y - 7410 COUNTY ROAD K,#102 v <br /> SIREN,WISCONSIN 54872 <br /> QON-PLUMBING SANIT T APPLICATION --)RECONNECTION <br /> POWTS REVISION �O <br /> Application Information—Type or Print <br /> Property Owner Name Property Legal Description <br /> aNF_r .t of 71cc�1 Gt.e si <br /> Av l�7bEZp RF,o SAkl� GL 1/4 la.s N.R W <br /> Property Owner's Mailing Address Lot Number Block Number <br /> lt,ovoS � - �' hr ee- of SirJe,, ffW pie 3 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> L! MtJ s��a-- ( (0moi P&I-39II vol,,,e 3 J J� <br /> Type of Building: (Check one)O State-Owned 0 City PH= <br /> Roo Q <br /> O I or 3 Family Dwelling.No.of Bedrooms: N I O yillage 1i�o-s <br /> O Public o of . ter <br /> Public Building/Land Use: (Explain the use/purpose for this permit,(i.e.. Parcel Tax Numbers) \. <br /> campground,festival,recreatWentertainmem event etc J) UZ-0 47�D& C i U C)a <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: <br /> �f Non-Plumbing Prrii Toilet,Restroom etc.) j Privy-Pit Toilet O Composting Toilet System <br /> O POWTS Reconne�ti6n O Privy—Vault Toilet(Vault size: ❑ Incinerating Toilet Device <br /> O POWTS Repair County M _gallons or _cubic yards) O Portable Restroom Unit <br /> O Revision State q O Other <br /> Responsibility Statement: (Check one or both O as appropriate.) <br /> ❑1,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> M4.the undersigned.assume responsibility for the installation of the non-plumbing sanitary system for which this permit is issued. <br /> Plumber's/Owner's Name(print) PI ber✓Owner's Si re: MP/MPRSW No.: <br /> Wantber's-Address(Street.City,State.Zip C ): <br /> �btlQ� P ------------------ <br /> ' <br /> c <br /> Office Use Only: <br /> 4// 0 Disapproved Permit Fee: CST No. Date Issued Iss g ni tore <br /> pproved OOwnerGiven Initial Adverse <br /> Dtermination -'S L.co7013( <br /> Comments: <br /> n <br /> ((n� <br /> �I <br /> Conditions of Approval/Reasons for Disapproval: <br /> �Ysfe�tual fin. PP�•v : 40 @ 81��d R _1� <br /> e� APR <br /> R/ii U <br /> N1N� rY � <br /> d <br />