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, <br /> • <br /> BURNETT COUNTY ZONING ADMINISTRA4,, � C. C D M <br /> 7410 COUNTY ROAD K, #102 1 <br /> SIREN, WISCONSIN 54872 Sv31s <br /> 715-349-2138 JUN 2 2322 <br /> NON-PLUMBING SANITARY PERMIT APPLICATIO1 ($1-: PBu�c,� <br /> POWTS CONNECTION/RECONNECTION ($50) Land Services Department <br /> Z <br /> Application Information (Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Property Owner Name Property Legal Description <br /> V IC,tON Pe✓rc)`fa GL ,t 1/4 1/4,53 roil"//yivk) <br /> Property Owner's Mailing Address Lot Number Block Number <br /> //G S-5 LI not S! 4/ 41 V. 41 e?if-7 <br /> City,State Zip Code Phone Number Subdivision Name or CSM Number <br /> G&k.e E tots, in A/ 1 S'S 'IJ ( ) <br /> • <br /> Type of Building: (Check one) 0 State-Owned 0 City I Nearest,R <br /> El I or 2 Family Dwelling-No.of Bedrooms:_ 0 Village !00 <br /> ❑ Public ®Town of SGet/- Fi e Nu ber <br /> a� en nd. <br /> Public Building/Land Use: [Explain the use/purpose for this permit,(i.e., Parcel Tax Number(s) (, <br /> campground,festival,recreation/entertainment event etc.)) 07- t-d-H0-/ii-)3-5'O.S-&Oa <br /> - 6190DD <br /> Type of Permit: Type of Non-Plumbing Device/System/Toilet/Unit: F <br /> ❑ Non-Plumbing(Privy,Toilet,Restroom etc.) 0 Privy—Pit Toilet 0 Composting Toilet System <br /> A'POWTS Reconnection i 0 Privy—Vault Toilet(Vault size: 0 Incinerating Toilet Device <br /> ❑ POWTS Repair County#. gallons or cubic yards) 0 Portable Restroom Unit <br /> ❑ Revision State#_ I ❑ Other <br /> Responsibility Statement: (Check one or both 0 as appropriate.) <br /> ,I,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑I,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) Plumber's/Owner's Signature: MP/MPRSW No.: Business Phone Number: <br /> Plumber's Address(Street,City,State,Zip Code): <br /> Office Use Only: <br /> 0 Disapproved Permit Fee. CST No. Date Issued Iss Of)} <br /> N <br /> Approved ❑Owner Given Initial Adverse 1 50 d-� ! r 3D��/ 7///2.9. <br /> � /l'"// <br /> Determination s (, ✓ �j t ( j <br /> Comments: ��. 1 i'Ja�1✓S <br /> ✓n e-e� a (1 <br /> 0 <br /> _1 <br /> c>- <br /> Conditions of Approval/Reasons for Disap roval: k1 <br /> SACC( Vo+ /i 0414 k ab/ 1`� <br /> lam'' <br /> Revised 6/7/02 W <br />