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BURNETT COUNTY <br /> SANITARY PERMIT—TRANSFER BETWEEN OWNER/CHANGE OF PLUMBER <br /> Permit Transfer Date: Al 164 ?? FEE: $75.00 <br /> Original Permit Issue Date: 9 liob. <br /> Expiration Date: 8103 _-,G <br /> Previous State Plan ID Number: 7/0`*_ New State Plan ID Number: (o(41 , O ) <br /> Office Permit Number: SAN- a - 74 <br /> 1/4 1/2, Section Q ,T 3 0 N.,R 16 W TOWNSHIP: 1.a,(kik <br /> Lot Block Subdivision Tax ID# n1(a p2. <br /> TRANSFER BETWEEN OWNERS: <br /> PREVIOUS SANITARY PERMIT HOLDER: NEW SANITARY PERMIT HOLDER: <br /> Name: Name: <br /> Address: Address: <br /> City, State,ZIP: City, State, and ZIP: <br /> Previous Permit Holder Signature: <br /> TRANSFER BETWEEN PLUMBERS <br /> *Revised plans must be submitted by installing plumber. <br /> PREVIOUS PLUMBER:iM / ,/ *INSTALLING PLUMBER: <br /> Name:LtNte • ►1 .V Name: �/li' c/e---- /f) / <br /> LC � , i4, <br /> Address 70 69c l eO *1 I 1.446 L Address: Ao e( <br /> City, State, ZII): 91eU Writ Id:614871 City, State, and ZIP: -j <br /> Phone: 3f 7 72$' <br /> MP/MPRSW#: 7L /` <br /> I, the undersigned, assume responsibility for installation of the private sewage system that has been <br /> previously approved for this property. <br /> Installing Plumber Signature: :, e2 <br /> Issuing Agent Signature. Date: E/ jl <br /> Check# �618a $ C E 0 W E <br /> . <br /> � <br /> REVISED 161 8; <br /> AUG 2 2 2022 <br /> Burnett County <br /> Land Services Department 1/,7/1g <br />