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BURNETT COUNTY ZONING ADMINISTRATION <br /> 7410 COUNTY ROAD K,#102 <br /> SIREN, WISCONSIN 54872 <br /> 715-349-2138 J <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 /> property Owner Nam, Progeny I-e .1 Desenptioo <br /> Ba.. K e IF41"y :>„ 1_ 6 1/4 1/4,S J 7 TYiAI elk <br /> property Owners Mailing Address Ful Number Block Nomber <br /> ej'0 J9 /9 e 1 <br /> City,StateZip Csde Phune Number Subdivision Man w CSM Number <br /> `rIfrrrA A"A, 3`.84}N V ` P /W <br /> Type of Building: (Check one)❑ State-Owned D City Nearest 6 17,/ <br /> * I or2Famhy Dwelling-No.of Bedrooms: ❑Village G <br /> ®T..of re Number6?S'J <br /> ❑ Public on All.. <br /> Public Building/Land Use: [Explain the use/purpose for Nie perma,b a. Pamal Tan Na idnn,, <br /> campground,festival recreafioNenrenainment event ete.d 67•*to-1•Ya-g.Z7-r-dr-Od(-4I10o0 <br /> oto-Y 27-�- 00 <br /> Type of Permit: I Type of Non-Plumbing Device/System/Potle WniU <br /> ❑ Non-Plumbing(Ptivy,Toilet,Restroom etc.) 1 ❑ Privy-Pit Toilet ❑ Composting Toilet System <br /> ) POWTS Reconnection ❑ Privy-Vault Toilet(Vauh sin: ❑ Incinerating Toilet Device <br /> ❑ POWTS Repair County# gallons or _cubic yards) ❑ Portable Restroom Unit <br /> ❑ Revision State#- ❑ Other <br /> Responsibility Statement: (Check one or both O as appropriate.) <br /> ,tat,the undersigned,assume responsibility for the POWTS activity for which this permit is issued. <br /> ❑1,theundersi red,assume res nsib t fur the instnllmion of the r. - lumbirtsadear,syslano For which Nml <br /> is rl is issued. <br /> Pluteers/Owner's Nars, prim) Plumbei s/Owner's Sienmure. MP/MPRSW Nu.: Busses Favor Number. <br /> �IGI_ o- �Gns 12- g()S.4S1 Y/S-FO clo t <br /> Plumbers Address(Ssmn,City,State,Zp Cade): <br /> -� 7-7JS tiv-ch s/`r. W1- S'frS93 <br /> Office Use Only: <br /> � ❑Disapproved Permit Fee: CST Ne 6m1vuW Issuing u",Sire <br /> AApproveJ ❑Owner Givar hshial Adverse SC.trp lag 160 !yam/f <br /> Decnn <br /> Comments: <br /> Conditions of Approval Bensons for Disapproval: <br /> - Top 4 d.y. r( iinirw ,G• sfrue>/ieres//y secrA9 <br /> -Nv an4f.%,.a.a( rwavtaS/ •ry 444,bl, 4&4.a we �ten.wiS�Ul �i.ri� <br /> f,kw crS fviD/ yr /, /sAvcfw'�. <br /> Ra,oned( 102 <br />