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Burnett County Zoning Administration <br /> BURNETT COUNTY GOVERNMENT CENTER <br /> 7410 County Road K, #102 Phone (715) 349-2138 <br /> Siren, Wisconsin 54872 <br /> � <br /> BURNETT COUNTY ANNUAL HOLDING TANK PUMPING REPORT <br /> OWNER NAME /; L �U« L 1�`i,z /Aja l'�¢— tI6 COMPUTER # 6,3 63-010 <br /> MAILING ADDRESS 30d,-J.�- 72 35 092& ,cY <br /> p��, CITY STATE ZIP <br /> PROPERTY ADDRESS/TANK LOCATION >�f <br /> PUMPER'S NAME �,Q/j/�/� LICENSE <br /> TYPE OF DISPOSAL: <br /> ( 1 LAND FILL. OWNER'S NAME <br /> LEGAL: 1/4 1/4 OR GOVT LOT SECTIONd7 T_WN RW <br /> LEGAL: 1/4 1/4 OR GOVT LOT SECTION T N R W <br /> (LIST ADDITIONAL SITES ON BACK) T <br /> ( 1 PUBLIC SEWAGE SYSTEM. GOVERNMENTAL ENTITY <br /> GALLONS PUMPED: <br /> JAN _ APRIL JULY OCT QQQ <br /> FEB MAY AUG _ NOV ago <br /> MAR JUNE SEPT DEC �9 <br /> TOTAL GALLONS PUMPEDll�vo YEAR,'2 � <br /> DOES THE OWNER HAVE A SIGNED CONTRACT WITH THE HAULER? ( ) YES (X) NO <br /> SIGNATURE OF PERSON COMLETING FORM. <br /> PUMPER ) R' ) <br /> DATE Cl_ <br />