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%2 <br /> BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K, #102 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 <br /> NON-PLUMBING SANITARY PERMIT APPLICATION ($150) <br /> POWTS CONNECTION/RECONNECTION ($50) <br /> Application Information (Type or Print) ATTACH A PLOT PLAN WITH THIS APPLICATION <br /> Properly Owner Name SS�� Property Legal Ucscripiion 44 ��uu.. <br /> F a0 ,n1f(6r, 5 1-.,# A1/lon ,mss/•bYf/ Ga. 1/4 im,S!J ,T4MN,R)-f�( <br /> W <br /> Property Owmrs Adeline Address Lot Number Block Number <br /> /d ts tfci AJ 5— <br /> City,Sum Zip Code Phone Numlwr Subdivision Name or CSM Number <br /> oa ret: U--c Se4vo 1 (7i )SJo. Jet Cosa.. C5y4*es. <br /> Type of Building: (Check one) ❑ State-Owned ❑CityNearest load <br /> N' tor'-Family Dwelling-No.of Bcdrooms:�._ ❑village •f/' - ,v <br /> ❑ Public WTown o1522w . Fin Number <br /> Public Building/Land Ilse: [Explain the use/purgtee for thispermn,(i.e., Pocel I as Number(,) <br /> ampground,(mesal,recreationlen rnamment event ac)I <br /> ,09-a-'/J7Y-13-5-15-DA'rs o 1S <br /> Tvpe of 1'ermil: Type of Non-Plumbing Device/Srsten)IToilel/Unit• <br /> ❑ Non-Plumbing(Privy,Toilet,Restroom etc.) ❑ Privy-Purroilet ❑ Composting Toilet System <br /> �40wl'S Reconnection ❑ Privy-Vault Toilct(Vaultsize: 13Incinerating Toilet Device <br /> ❑ 1'0VV1 S Repair County# 3 gallons or _cubic yards) ❑ Portable Resuoom Unit <br /> 11Revision State H,�i3ac�. ❑ Other <br /> Responsibility Statement: (Check one or both❑as appropriate.) <br /> ❑ I,the undersigned,assume responsibility for the POWTS activity for which this permit is issued <br /> ❑I,the undcoeiencd,assume responsibility for the installation ofthe non-plumbing sanitary system for which this permit is issued. <br /> rPhimbcrsl11"re,I Name(pnno Plumber's/Oxmer's Sign' Ml'/MPRSW Nu.: nosiness Phone Number: <br /> 1LAPrh.a 225851 JS /5 <br /> Plunfior's Adda.s tSocet,City,Steno,zip Code. <br /> W). SYOpp <br /> Office Use Only: <br /> ❑Uisappus'N Permit Fee: CST Nu. Date Issued Issuing Agent Signature <br /> �Apprmal ❑Owmv(iiven Initial Adverse <br /> Ixterminmion x. 06 /L6/950 try/y <br /> Comments: <br /> Tl l / raor.l o sys P .wd exu��l 3. <br /> Conditions of Apprms al/Reasons for Disapproval: <br /> 0 4""S d "J; /b Fx SiLi..r,?Iei1.� nasrc ' Z /z/ <br /> dwell I5 b,,.,7-/, <br /> Revised W71W <br />