Laserfiche WebLink
BURNETT COUNTY ZONING ADNHNISTRATION <br /> 7410 COUNTY ROAD K,#102 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION($50) <br /> POWTS RECONNECTIO (-$25) <br /> POWTS REVISION($ <br /> Application Information—Type or Print <br /> Property Owner Nam /� L q Property Lew Dominus! <br /> /�JII1IQ/ n ��'(%' %, 'l CO-->err-I UQ.(' G(, OL 9 1/4 1/1 S.33 TL10 N.RW <br /> Properly Ownces Mailing Address Lot Number Block Number <br /> I6 9LF i Sher,d hvz s a <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> 554l 95a),939- CSm v. 3 3� <br /> T pe of Building: (Check one)O State-Owqc4 O City N Road <br /> I or 2 Family Dwelling-No.of Bedrooms: 'I O Village Oo k j ,2d - a <br /> 0 Public '9 Town of Fire N <br /> Public Buildin and Use: [Explain me / <br /> g/L [ xp uWpupae for this permit.(i.e. Parcel Tax Number(s) <br /> campground,festival,recratiaJemensinment event ac.)] <br /> OaD- L/333 -D3-860 <br /> Type of Permit: Type of Non-Plumbing Device/System/Pollet/Unit: <br /> O Non-Plumbing(Privy,Toilet,Restroom etc.) O Privy—Pit Toilet O Composting Toilet System <br /> p'POWTS ReconneeionO Privy—Vault Toilet(Vault size: O Incinerating Toilet Device <br /> D POWTS Repair County# 2 /9(i gallons or _cubic <br /> O Revision State# K SD O Other ❑ Portable Restroom Unit <br /> Responsibility Statement: (Check one or both 0 as appropriate.) <br /> O 1,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑1,the undersigned,assume responsibility for the installation of the!=Iumbinit sanitary for which this permit is issued. <br /> Plwober's/Owner's Name(print) PI ber Owner's MP/MPRSW No.: Business Ph nae Number: <br /> Wry &4'51-]6Jm ::z 2727/ <br /> Plumber's Addnxt(Street,City,Sate.Zip Code): <br /> Office Use Only: <br /> O Disapproved Permit Fa: CST No. are WNW t Si <br /> O Approved ❑Owner Diva Initial Adverse <br /> Determination <br /> Comments: <br /> Conditions of Approval/Reasons for Disapproval: <br /> Revised tY7/02 <br />